The effect of transdermal scopolamine plus intravenous dexamethasone for the prevention of postoperative nausea and vomiting in patients with epidural PCA after major orthopedic surgery

Transdermal Scopolamine as an Adjunct to Multimodal Pain Management in Patients Undergoing Total Joint Arthroplasty

BACKGROUND

Postoperative nausea and vomiting (PONV) after surgery degrades patient experience, tolerance of pain medication, rehabilitation progress, and functional outcomes. Given the importance of early rehabilitation following total joint arthroplasty (TJA), we asked whether transdermal scopolamine is effective in reducing rates of PONV and improving functional outcomes following TJA.

METHODS

We retrospectively reviewed the charts of 1580 consecutive patients who underwent TJA between 2014 and 2017 and compared patients before the addition of the scopolamine patch (control group) to those after the addition (study group). Patients were given the scopolamine patch in the holding area unless contraindicated. A total of 495 patients were excluded. Charts were reviewed for PONV, demographic information, surgical time, length of stay, distance walked with physical therapy, and Visual Analog Scale pain scores. Student t-test was used to compare continuous data and chi-square was used for categorical variables.

RESULTS

The incidence of PONV was significantly lower in the study group compared to the control group (14.4% vs 29.3%, P < .0001). Patients who were given scopolamine had lower Visual Analog Scale pain scores on postoperative days (POD) 0 through 2 (P < .01), were able to walk further distances on POD 0 through 3 (P < .001), and received fewer morphine equivalents on POD 1 and 2 (P < .001). Greater morphine equivalents were received by the study group on POD 0.

CONCLUSION

Use of a scopolamine patch was associated with significant reduction in PONV and improvement in functional outcomes following TJA. These data support the use of transdermal scopolamine as part of a multimodal, perioperative pain protocol in patients undergoing TJA.

A comparison of palonosetron and dexamethasone for postoperative nausea and vomiting in orthopedic patients receiving patient-controlled epidural analgesia

Background

Postoperative nausea and vomiting (PONV) is one of the major concerns after anesthesia and surgery, and it may be more frequent in orthopedic patients receiving patient-controlled epidural analgesia (PCEA). The purpose of this study was to compare the effect of palonosetron and dexamethasone on the prevention of PONV in patients undergoing total joint arthroplasty and receiving PCEA.

Methods

Patients scheduled for total hip or knee arthroplasty under spinal anesthesia/PCEA were randomly allocated to receive either intravenous palonosetron (0.075 mg, n = 50) or dexamethasone (5 mg, n = 50). Treatments were administered intravenously to the patients 30 min before the beginning of surgery. The total incidence of PONV and incidence in each time period, severity of nausea, need for rescue anti-emetics, pain score, and adverse effects during the first 48 h postoperatively were evaluated.

Results

The total incidence of PONV was lower in the palonosetron group compared with the dexamethasone group (18.4% vs. 36.7%, P = 0.042), but there were no statistically significant differences in incidence between the groups at all time points. No significant intergroup differences were observed in the severity of nausea, use of rescue anti-emetics, pain score, and adverse effects.

Conclusions

Although there were no significant differences in the incidence of PONV between the treatment groups at all time points, intravenous palonosetron reduced the total incidence of PONV in orthopedic patients receiving PCEA compared with dexamethasone.

Triple Therapy with Scopolamine, Ondansetron, and Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Moderate to High-Risk Patients Undergoing Craniotomy Under General Anesthesia: A Pilot Study

Introduction

Postoperative nausea and vomiting (PONV) is one of the most common complaints from patients and clinicians after a surgical procedure. According to the current Society of Ambulatory Anesthesia Consensus Guidelines, the general incidence of vomiting and nausea is around 30 and 50%, respectively; and up to 80% in high-risk patients. In previous studies, the reported incidence of PONV at 24 h after craniotomy was 43–70%. The transdermal scopolamine (TDS) delivery system contains a 1.5-mg drug reservoir, which is designed to deliver a continuous slow release of scopolamine through intact skin during the first 72 h of patch application. Therefore, we designed this single arm, non-randomized, pilot study to assess the efficacy and safety of triple therapy with scopolamine, ondansetron, and dexamethasone to prevent PONV.

Materials and methods

In the preoperative area, subjects received an active TDS 1.5 mg that was applied to a hairless patch of skin in the mastoid area approximately 2 h prior to the operation. Immediately after anesthesia induction, all patients received a single 4 mg dose of ondansetron IV and a single 10 mg dose of dexamethasone IV. Patients who experienced nausea and/or vomiting received ondansetron 4 mg IV as the initial rescue medication. Postoperative nausea and vomiting assessments were performed for up to 120 h after surgery.

Results

A total of 36 subjects were analyzed. The overall incidence of PONV during the first 24 h after neurological surgery was 33% (n = 12). The incidence of nausea and emesis during the first 24 h after surgery was recorded as 33% (n = 12) and 16% (n = 6), respectively.

Conclusion

Our data showed that this triple therapy regimen may be an efficient alternative regimen for PONV prophylaxis in patients undergoing neurological surgery with general anesthesia. Further studies using regimens affecting different receptor pathways should be performed to better prove the efficacy and safety in the prevention or delay of PONV.

The impact of patients controlled analgesia undergoing orthopedic surgery

INTRODUCTION

The currently common musculoskeletal disorders have been increasingly treated surgically, and the pain can be a limiting factor in postoperative rehabilitation.

RATIONALE

Patient controlled analgesia (PCA) controls pain, but its adverse effects can interfere with rehabilitation and in the patient discharge process. This study becomes important, since there are few studies evaluating this correlation.

OBJECTIVES

To compare the outcomes of patients who used and did not use patient controlled analgesia in postoperative orthopedic surgery with respect to pain, unscheduled need for O2 (oxygen), and time of immobility and in-hospital length of stay.

METHODS

This is an observational, prospective study conducted at Hospital Abreu Sodré from May to August 2012. The data was daily obtained through assessments and interviews of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), thoracolumbar spine arthrodesis (long PVA), cervical spine arthrodesis (cervical AVA) and lumbar spine arthrodesis (lumbar PVA).

RESULTS

The study showed some differences between groups, namely: the painful level was higher in the group undergoing lumbar PVA without PCA compared with the group with PCA (p=0.03) and in the group of long PVA without PCA in the early postoperative period. This latter group used O2 for a longer time (p=0.09).

CONCLUSION

In this study, PCA was useful for analgesia in patients undergoing lumbar PVA and probably would have influenced the usage time of O2 in the group of long PVA in face of a larger sample. The use of PCA did not influence the time of leaving the bed and the in-hospital length of stay for the patients studied.

The effect of transdermal scopolamine for the prevention of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) is one of the most common and undesirable complaints recorded in as many as 70-80% of high-risk surgical patients. The current prophylactic therapy recommendations for PONV management stated in the Society of Ambulatory Anesthesia (SAMBA) guidelines should start with monotherapy and patients at moderate to high risk, a combination of antiemetic medication should be considered. Consequently, if rescue medication is required, the antiemetic drug chosen should be from a different therapeutic class and administration mode than the drug used for prophylaxis. The guidelines restrict the use of dexamethasone, transdermal scopolamine, aprepitant, and palonosetron as rescue medication 6 h after surgery. In an effort to find a safer and reliable therapy for PONV, new drugs with antiemetic properties and minimal side effects are needed, and scopolamine may be considered an effective alternative. Scopolamine is a belladonna alkaloid, α-(hydroxymethyl) benzene acetic acid 9-methyl-3-oxa-9-azatricyclo non-7-yl ester, acting as a non-selective muscarinic antagonist and producing both peripheral antimuscarinic and central sedative, antiemetic, and amnestic effects. The empirical formula is C17H21NO4 and its structural formula is a tertiary amine L-(2)-scopolamine (tropic acid ester with scopine; MW = 303.4). Scopolamine became the first drug commercially available as a transdermal therapeutic system used for extended continuous drug delivery during 72 h. Clinical trials with transdermal scopolamine have consistently demonstrated its safety and efficacy in PONV. Thus, scopolamine is a promising candidate for the management of PONV in adults as a first line monotherapy or in combination with other drugs. In addition, transdermal scopolamine might be helpful in preventing postoperative discharge nausea and vomiting owing to its long-lasting clinical effects.

Consensus guidelines for the management of postoperative nausea and vomiting

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

Postembolization syndrome after hepatic transarterial chemoembolization: effect of prophylactic steroids on postprocedure medication requirements

PURPOSE

To evaluate the impact of prophylactic use of dexamethasone and scopolamine on analgesic and antiemetic agent requirements after transarterial chemoembolization.

MATERIALS AND METHODS

A total of 148 patients underwent 316 rounds of chemoembolization for hepatocellular carcinoma at a single institution over a 17-month period. Patient charts were retrospectively reviewed for demographic data, procedural technique, and use of analgesic and antiemetic medications. Patients were grouped into three categories: group A received steroid prophylaxis before and after the procedure, group B received steroid prophylaxis before the procedure only, and group C received no steroid prophylaxis.

RESULTS

Analysis was performed on 125 patients undergoing 252 procedures. Demographics were similar among groups. Overall, 86 (68.8%) were male, and mean age was 62 years (range, 39-82 y). Ninety-one patients (75%) had Child-Pugh class A cirrhosis and 25% had Child-Pugh class B cirrhosis. Dexamethasone was not significantly associated with decreased analgesic agent use (P = .6). Group A patients used significantly fewer antiemetic agents (Δ = 0.89; P = .007) compared with group C. A transdermal scopolamine patch was not associated with reduced use of antiemetic agents (P = .3). Age was inversely associated with analgesic (P <.001) and antiemetic agent use (P = .004). Men received significantly fewer antiemetic agents than women (P = .002), whereas there was no significant difference in analgesic agent use (P = .7).

CONCLUSIONS

The use of steroids did not affect analgesic agent use and had a minor effect on antiemetic requirements. The use of a scopolamine patch was not associated with reduced antiemetic agent use.

Perspectives on transdermal scopolamine for the treatment of postoperative nausea and vomiting

Transdermal scopolamine, a patch system that delivers 1.5 mg of scopolamine gradually over 72 hours following an initial bolus, was approved in the United States in 2001 for the prevention of postoperative nausea and vomiting (PONV) in adults. Scopolamine (hyoscine) is a selective competitive anatagonist of muscarinic cholinergic receptors. Low serum concentrations of scopolamine produce an antiemetic effect. Transdermal scopolamine is effective in preventing PONV versus placebo [relative risk (RR)=0.77, 95% confidence interval (CI), 0.61-0.98, P = 0.03] and a significantly reduced risk for postoperative nausea (RR=0.59, 95% CI, 0.48-0.73, P < 0.001), postoperative vomiting (RR=0.68, 95% CI, 0.61-0.76, P < 0.001), and PONV (RR 0.73, 95% CI, 0.60-0.88, P = 001) in the first 24 hours after the start of anesthesia.

Penehyclidine enhances the efficacy of tropisetron in prevention of PONV following gynecological laparoscopic surgery

PURPOSE

Postoperative nausea and vomiting (PONV) are common complications after gynecological laparoscopic surgery. Because monotherapy with antiemetics is insufficient, combinations of various antiemetics are often recommended by experts. In this study, our purpose was to find out whether penehyclidine could enhance the efficacy of tropisetron in preventing PONV.

METHODS

With hospital ethics committee approval, we investigated 120 women undergoing gynecological laparoscopic surgery receiving prophylactic tropisetron (0.1 mg/kg; maximal dose, 5 mg) (group T) or tropisetron (0.1 mg/kg; maximal dose, 5 mg) plus penehyclidine (0.01 mg/kg; maximal dose, 1 mg) (group TP), or penehyclidine (0.01 mg/kg; maximal dose, 1 mg) (group P). The incidence of vomiting, the intensity of nausea (assessed by a visual analogue scale [VAS]), antiemetic rescues, and adverse effects were recorded at 2, 6, 12, and 24 h after surgery in the gynecological ward by a visiting nurse anesthetist who was unaware of the treatments. Collected data were analyzed using analysis of variance (ANOVA) and the χ(2) test. Continuous variables were expressed as means ± SD, and non-continuous variables were expressed as n (%).

RESULTS

The overall incidence of vomiting was 28.3 % (34/120) in our study. The incidence of vomiting was significantly lower in group TP (4 cases, 10 %) than that in group T (12 cases, 30 %) and group P (18 cases, 45 %). The incidence of vomiting in group TP was also significantly lower than that in group T at 0-2 h and 2-6 h postoperatively and it was also significantly lower than that in group P at 0-2 h, 2-6 h, 6-12 h, and 12-24 h postoperatively. The incidence of vomiting was significantly lower in group T than that in group P at 12-24 h postoperatively. The VAS of nausea was significantly lower in group TP than that in group T and group P at 2 and 6 h after surgery. It also showed a significant higher score in group P than that at group T and group TP at 12 and 24 h. Within group P, the VAS of nausea was significantly lower at 2 h postoperatively than that at 24 h.

CONCLUSIONS

Penehyclidine showed less efficacy in preventing PONV than tropisetron; however, compared with tropisetron or penehyclidine monotherapy, prophylactic medication with tropisetron plus penehyclidine significantly reduced the incidence of vomiting and decreased the intensity of nausea in women undergoing gynecological laparoscopic surgery.

Randomized, double-blind comparison of oral aprepitant alone compared with aprepitant and transdermal scopolamine for prevention of postoperative nausea and vomiting

BACKGROUND

Aprepitant blocks the emetic effects of substance P. Scopolamine antagonizes muscarinic type 1 and histamine type 1 receptors. This study compares monotherapy and multimodal therapy by looking at complete response, nausea, vomiting, and rescue medication in patients at high risk for postoperative nausea and vomiting (PONV) treated with oral aprepitant with or without scopolamine.

METHODS

We enrolled 120 patients in this randomized, double-blind trial. Inclusion criteria were: >18 yr old, ASA I-III, two or more Apfel four-point risk factors, undergoing an elective surgical procedure with a high risk of PONV expected to last at least 60 min. The primary outcome variable was complete response, that is, no emesis and no rescue therapy from 0 to 24 h. The outcomes measured included the incidences of nausea, vomiting, their composite, and the need for rescue medication.

RESULTS

The aprepitant alone and aprepitant with scopolamine did not differ in complete responses (63% vs 57%, P=0.57) or net clinical benefit (26% vs 19%, P=0.38). The number who did not experience PONV and who used rescue medication did not differ. The incidence of PONV in the post-anaesthesia care unit did not differ nor did the use of rescue medications.

CONCLUSIONS

This trial evaluating the effectiveness of aprepitant alone and in combination with scopolamine showed no difference between treatment groups. The primary objective, complete response, and secondary objectives, incidences of nausea, vomiting, their composite, and the need for rescue medication, all showed no statistical difference.

Ramosetron for the prevention of postoperative nausea and vomiting (PONV): a meta-analysis

Background

Postoperative nausea and vomiting (PONV) remains a challenge for patients and health professionals despite various newly developed prophylactic interventions. We reviewed the efficacy and safety of ramosetron in randomized controlled trials (RCTs) for the prevention of PONV.

Methods

We reviewed 18 randomized controlled trials investigating the efficacy and safety of ramosetron in comparison with placebo or any other drugs. Relevant studies were searched in the MEDLINE, SCOPUS, and the Cochrane database libraries. Our end points of concern were prevention of PONV and adverse effects as dichotomous data.

Results

The prophylactic effect of 0.3 mg ramosetron was observed in early PON (relative risk, RR: 0.4; 95% CI 0.3-0.6), early POV (RR: 0.3; 95% CI 0.1-0.6), late POV (RR: 0.3; 95% CI 0.1-0.6), but not late PON (RR: 0.7; 95% CI 0.5-1.0). Compared with placebo, the efficacy of 0.3 mg ramosetron in adults and 6 µg/kg in children were consistently beneficial in preventing PONV overall (RR: 0.4; 95% CI: 03-0.6). The effects of 0.3 mg ramosetron and 3 mg granisetron were similar. No serious side effects or adverse events resulted from ramosetron and other active drugs, and incidence was similar to those of the placebo group.

Conclusions

Ramosetron is effective and safe in children and adults without serious adverse effects compared with placebo or other active drugs, as shown in pooled data of RCTs, in terms of the prevention of PONV.

Pharmacologic management of postoperative nausea and vomiting

INTRODUCTION

As advances in the safety and efficacy of surgery and anesthesia have been made, other complications such as postoperative nausea and vomiting (PONV) have become more apparent. PONV occurs after 30% of all surgeries, and incidences as high as 80% have been reported among patients at high risk.

AREAS COVERED

This review provides a brief overview of the etiology and mechanisms of emesis and of known risk factors for PONV. It also covers pharmacologic therapies, appropriate management strategies, prophylactic strategies, multimodal therapy and rescue treatment.

EXPERT OPINION

The main triggers for PONV are general anesthesia with inhalational anesthetics and opioids. When given to susceptible patients, e.g., females, the risk may be as high as 80%. In such patients, opioid-free regional anesthesia would be the most logical approach. However, if general anesthesia is needed, we prefer total intravenous anesthesia as it eliminates the use of inhalational anesthetics and reduces the risk for PONV. Importantly, efficacy of antiemetic interventions is independent as long as interventions have different mechanisms. Thus, for practical purposes, we prefer to titrate the use of antiemetics according to the validated Apfel simplified risk score. If a patient has 0, 1, 2, 3 or 4 of the four risk factors, we apply a similar number of antiemetic strategies.

Transdermal scopolamine for the prevention of postoperative nausea and vomiting: a systematic review and meta-analysis

BACKGROUND

Transdermal scopolamine (TDS) is a potential long-acting prophylactic antiemetic initially developed to prevent motion sickness. TDS is a centrally acting anticholinergic agent that was approved in 2001 by the US Food and Drug Administration for the prevention of postoperative nausea and vomiting (PONV). Although TDS has been reported to be clinically efficacious in the prevention of PONV, several adverse events (AEs), such as sedation, dry mouth, blurred vision, central cholinergic syndrome, and confusion (particularly in elderly patients with mild cognitive impairment), are potential concerns.

OBJECTIVE

The aim of this study was to explore the efficacy and tolerability of TDS in the prevention of PONV in adults.

METHODS

A systematic search of PubMed, EMBASE, and the Cochrane Library for randomized controlled trials in adults that compared the effects of TDS and placebo on postoperative nausea, vomiting, and PONV was conducted in March 2009, and an update was conducted in July 2010. Without any language restrictions, a search with the following terms was performed: postoperative, postoperative, postanesthe*, postanaesthe*, post-anesthe*, post-anaesthe*, anesthesia, anaesthesia, surgery, surgeries, surgical, nausea, vomiting, emesis, retching, scopolamine, and hyoscine. Identified studies were then hand-searched for further relevant literature.

RESULTS

Data from 25 randomized controlled trials were analyzed (N = 3298). In the postanesthesia care unit, TDS was associated with a significantly reduced risk for postoperative nausea compared with placebo (relative risk [RR] = 0.77; 95% CI, 0.61-0.98; P = 0.03). TDS was also associated with a significantly reduced risk for postoperative nausea (RR = 0.59; 95% CI, 0.48-0.73; P < 0.001), postoperative vomiting (RR = 0.68; 95% CI, 0.61-0.76; P < 0.001), and PONV (RR = 0.73; 95% CI, 0.60-0.88; P = 0.001) during the first 24 hours after the start of anesthesia. TDS appeared to be effective compared with placebo in the prevention of postoperative nausea when treatment was initiated the night before (early application) (RR = 0.56; 95% CI, 0.41-0.75; P < 0.001) or on the day of surgery (late application) (RR = 0.61; 95% CI, 0.47-0.79; P < 0.001). TDS was associated with a higher prevalence of visual disturbances at 24 to 48 hours compared with placebo (RR = 3.35; 95% CI, 1.78-6.32). Analyses of confusion and other AEs did not show a significant association with TDS.

CONCLUSIONS

In this systematic review and metaanalysis, TDS was associated with significant reductions in PONV with both early and late patch application during the first 24 hours after the start of anesthesia. TDS was associated with a higher prevalence of visual disturbances at 24 to 48 hours after surgery, but no other AEs, compared with placebo.

Neurokinin-1 and novel serotonin antagonists for postoperative and postdischarge nausea and vomiting

PURPOSE OF REVIEW

This review will address novel options for the prevention and treatment of postoperative and postdischarge nausea and vomiting (PONV and PDNV) after ambulatory anesthesia. In particular, this paper will review the characteristics of neurokinin-1 receptor antagonists (NK1-RAs) and the new serotonin receptor antagonist (5HT3-RA) palonosetron. Finally, we will discuss strategies for prophylaxis and treatment of PONV and PDNV that address the unique concerns in ambulatory surgery patients.

RECENT FINDINGS

First, although PONV has previously been recognized to be a problem for inpatients, new research suggests that the incidence of PDNV after ambulatory surgery may be as high as 35%. Second, NK1-RAs, including aprepitant, the first approved member of this family, are significantly more efficacious than any other antiemetic for the prevention of vomiting. They are however not more effective than other interventions for the control of nausea. Third, the next generation of 5HT3-RAs, such as palonosetron, does not affect the QT interval and has a half-life of 40 h that should be advantageous for the prevention of PDNV.

SUMMARY

Because of the high incidence of PDNV, a predictive model for PDNV would be helpful to determine appropriate antiemetic interventions for each individual patient. Drugs that may be particularly favorable are the novel NK1-RA aprepitant and the next generation 5HT3-RA palonosetron.