sign in sign up
<<
Home , Alosetron, Cilansetron, Granisetron

JK SCIENCE

ORIGINAL ARTICLE Prophylactic Therapy with , and in Patients Undergoing Laparoscopic Cholecystectomy Under GA

Vishal Gupta, Renu Wakhloo, Anjali Mehta, Satya Dev Gupta

Abstract The aim of the present study was to compare the antiemetic effect of intravenous Granisetron, Ondansetron & Metoclopramide in a randomized blinded study for prophylaxis of post operative and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy under general anaesthesia. 60 patients (ASA I & II) undergoing laparoscopic cholecystectomy under general anaesthesia were randomly allocated into three equal groups (n=20). Emetic episodes in first 24 hours were recorded and compared in different study groups. Results were analyzed. Minimal emetic episodes were observed in early post-operative period (1-12hrs) in patients who had received intravenous granisetron in comparison to ondansetron and metoclopramide. However, after 12 hours emesis free periods were statistically insignificant between group A and B while patients in group C had no antiemetic effect.

Keywords Post Operative Nausea and Vomiting (PONV), Granisetron, Ondensetron, Metoclopramide

Introduction The most common and distressing symptoms, which vascular anastomoses and increased intracranial follow anaesthesia and surgery, are pain and emesis. The pressure(4). The anaesthetic consequences are aspiration syndrome of nausea, retching and vomiting is known as pneumonitis and discomfort in recovery. For institutions 'sickness' and each part of it can be distinguished as a there is increased financial burden because of increased separate entity (1). PONV (post operative nausea and nursing care, delayed discharge from Phase I and II vomiting) has been characterized as big 'little problem(2) recovery units and unexpected admissions. Hence, and has been a common complication for both in patients prophylactic antiemetic therapy is needed for all these and out patients undergoing virtually all types of surgical patients. procedures. Sometimes nausea and vomiting may be more The consequences of PONV are physical, surgical distressing especially after minor and ambulatory surgery, and anaesthetic complications for patients as well as delaying the hospital discharge(5). There are a number financial implications for the hospitals or institutions(3). of factors influencing the occurrence of PONV which Physical consequences include sweating, pallor, includes patient factors (age, gender, obesity, anxiety, tachycardia, stomach ache, increased chances of history of motion sickness or previous PONV and gastro oesophageal tear, wound dehiscence and electrolyte paresis), operative procedures, anesthetic techniques imbalance. Surgical consequences include disruption of (drugs for general anesthesia, regional anesthesia and

From the Department of Anaesthesiology and ICU, Government Medical College, Jammu, J&K- India. Correspondence to : Dr. Renu Wakhloo, Senior Resident, Department of Anaesthesiology, Govt. Medical College-Jammu,J&K-India

74 Vol. 10 No. 2, April-June 2008 JK SCIENCE monitored anesthesia care) and post-operative factors weight. Maintenance of anaesthesia was done with nitrous (pain, dizziness, ambulation, oral in-take and opioids). oxide (67%), oxygen (33%), and muscle Laparoscopic surgery is one condition, where risk of relaxation maintained with Inj. pancuronium 0.05-0.1 mg/ PONV is particularly pronounced. This increased risk of kg body weight with intermittent positive pressure PONV is due to pneumo-peritoneum causing stimulation ventilation to maintain ETCO2 between 4.6-5.2 Kpa. An of mechanoreceptors in the gut (6). orogastric tube was introduced and suction was applied Plenty of antiemetic drugs are available these days to empty the stomach of air and other contents, the which include drugs (, orogastric tube was removed at the completion of surgery ), antagonist drugs (, before tracheal extubation. and metoclopramide), antihistaminic Abdominal insufflation for laparoscopic procedure was drugs ( hydroxzine), 5HT3 receptor achieved with CO2 and intrabdominal pressure was antagonists (ondansetron, granisetron, ) and maintained between 1.3 to 1.8Kpa. At the end of the steroids (). In spite of plenty of anti-emetic surgery residual neuromuscular blockage was antagonized drugs available no single drug is 100% effective in by injection glycopyrrolate 10µg/kg and neostigmine 0.05 prevention of PONV and combination therapy has got a mg/kg and the patient was extubated. Post operative pain lot of side effects.The present study was undertaking to relief was provided with injection diclofenac sodium-75 compare the antiemetic effects of IV granisetron, mg intramuscular when pain score was > 4(VAS). All ondanisetron and metoclopromide for prophylaxis of post- patients received supplementations and investigator who operative nausea and vomiting in patients undergoing collected post-operative data was blinded to study drug laparoscopic cholecystectomy. administered while in the recovery ward. Material & Methods Episodes of PONV were determined and noted in first After approval from Institutional Ethical Committee 24 hours after operation at different time interval of 1, 4, 60 female patients aged between 20-60 years who were 9, 12, 18 and 24 hours. At the end of each interval the classified as ASA grade I and II were included in the anaesthesiologist registered whether vomiting has study. An informed consent from each patient was occurred and asked the patients whether they felt obtained. Patients with history of previous exposure to nauseated. The result was scored as Nausea =1, general anaesthesia, gastrointestinal disease, motion Retching=2 and vomiting=3. sickness, PONV, pregnancy and menstruation or those Nausea was defined as subjective unpleasant sensation who had taken antiemetic drugs within 24 hours of associated with the urge to vomiting. Retching was operation were excluded from the study. defined as spasmodic, rhythmic contraction of the On arrival to the operation theatre routine monitoring respiratory muscles without expulsion of gastric contents devices were attached. SpO2, heart rate, ECG, blood and vomiting was defined as forceful expulsion of gastric pressure and ETCO2 were observed throughout study contents. Patients who experienced any episode of period. All patients received 0.2mg of glycopyrrolate i/m nausea, retching and vomiting were given injection ½ hour before operation. Using double blind randomization metoclopramide 10mg intravenous slowly as rescue technique these patients were given either Group treatment. Patient who received antiemetic were A(granisetron 3mg), Group-B(ondansetron 4mg) or classified as treatment failure and were considered to Group-C (metoclopramide 10mg). All the drugs were experience both nausea and vomiting. diluted in 50ml normal saline and given slowly 10 minutes Side effects were registered during initial 6 hours in before induction. Analgesia was provided with injection 1-2mg/Kg. Induction of anaesthesia was done recovery ward. For example headache, dizziness, dry with injection. sodium thiopentone 5mg/kg and intubation mouth, extra pyramidal symptoms, restlessness or any was facilitated with injection succinylcholine 2mg/kg body other abnormal movement.

Vol. 10 No. 2, April-June 2008 75 JK SCIENCE

Statistical Analysis: Data was analyzed using Chi square Discussion test and analysis of variance. Differences were PONV is amongst the most common complications considered significant when P<0.05. following anaesthesia and surgery with a selectively high Results incidence after laparoscopic cholecystectomy. The The treatment groups were comparable with regards etiology behind the PONV following laparoscopic to patient demographics (Table I). Complete control of cholecystectomy is complex and multifactorial and is PONV (no emesis, no rescue treatment for 24 hours dependent on variety of factors including patient after administration of study agent) was achieved in 30% demographics, type of surgery, anaesthetic technique and of cases in group A, in 55% of cases in group B and in postoperative care. Patient related factors are age, sex, 5% of cases in group C. During 0-12 hours emesis free obesity, a history of motion sickness, menstruation and period was 40%, 75% and 10% in groups A, B and C history of PONV(6). In this clinical trial however, the respectively. Stating it the other way 60% patients in group treatment groups were similar with respect to patient A, 25% patients in group B and 90% patients in Group-C demographics, operative management and patient related experienced episodes of nausea and vomiting (Graph I) factors. If such factors had not been controlled the number in first 12 hours. The difference was statistically significant of patients who were observed to be emesis free in the between groups A and B in the first 12 hours but not present study would have changed. All patients were beyond that (Table II). The difference in emetic sequaly anaesthetized and operated by the same team of was significant between group A and C throughout 24 anaesthesiologists and surgeons. Duration of surgery and hours (Table III). The incidence of emesis was also agents used for anaesthesia were also similar. statistically significant between B and C during entire 24 The introduction of 5HT3 () receptor hrs period (Table IV). However from 12-24 hours the antagonists in 1991 (7) has heralded a major advance in difference between group A and B was not much treatment of PONV because of absence of adverse significant.Thus granisetron was definitely found to be effects that were± observed with commonly used superior to the other too agents for suppression of PONV. antiemetic drugs. The 5HT3 receptor antagonists produce Table I: Demographic Data with Regards to Age and Weight of no sedation, no extra pyramidal symptoms or adverse Study Groups effects on vital signs and do not interact with other Demographic Data Group-A Group-B Group-C anaesthetic agents. Current 5HT3 receptor antagonists are granisetron, , ondansetron, , Age(Yrs) 38 ±7.7 39.5±11 38.75±7.85 , , tropisetron and dolasetron. All Weight(Kg) 50.1 ±5.5 50.6±7.15 52.2±6.3 the 5HT3 receptors antagonists have the basic double P>0.05 NS nitrogen ring back-bone for their chemical structure. This may be the chemical site of action of 5HT3 receptor Table II: Comparative Evaluation of Emetic Sequelae in Groups antagonist on serotonin (8). 5HT3 receptors analogues Groups Emesis with Emesis in Emesis in 12- Emesis in are routinely used now a day to prevent PONV. in first 6 hrs 6-12 hrs 18 hrs 18-24 hrs Y. Fuji et al in 2000 (9) reported that granisetron is A 10/20 2/10 0/8 2/8 statistically superior to and metoclopramide for prevention of PONV. Results showed the incidence B 2/20 3/18 4/14 0/14 of PONV to be 13%, 30%, 33% and 37% after C 16/20 2/4 1/2 0/1 administration of granisetron, droperidol, metoclopramide and placebo respectively (P<0.05). Chi 19.82 2.16 3.65 4.11 square These findings are in agreement with our study where test P=0.00004 P=0.33 P=0.16 P=0.12 incidence of PONV was 30% with granisetron 95% with metoclopramide (P<0.001).

76 Vol. 10 No. 2, April-June 2008 JK SCIENCE

Comparison of single dose granisetron to prevent 2. Kapur PA. The big "little problem". Anaesthesia Analgesia PONV induced by moderately emetogenic 1991; 73: 243-45. has been done which concluded that single oral dose of 3. White PF, Watcha MF. Post operative nausea & vomiting: Its etiology and treatment. Anaesthesiology granisetron 2mg results in equivalent level of protection 1992; 77: 162-84. against nausea and vomiting as intravenous Ondansetron 4. Andrew PLR. Physiology of nausea and vomiting. Br J 8 - 16 mg (10). Anaesthesia 1992; 69: 2 - 19. Bhattacharaya D et al (11) in 2001, reported lower 5. Islam S, Jain P N. Post Operative Nausea & vomiting incidence of emesis sickness (P<0.05) in early post (PONV): A review article. Ind J Anaesthesiology 2004; 48: operative period (Ist six hours) in patients who received 253-58. intravenous granisetron in comparison to those who 6. Sarkar M, Sarkar A , Dewoolkar L , Charan S. Comparative Study of single dose intravenous ondansetron and received ondansetron and placebo. In this study emetic metoclopramide as a premedication for prevention of post episodes were 7% with granisetron as compared to 20% operative nausea and vomiting in obstetrical laparoscopic seen with ondansetron. This is in agreement with our surgery under general anaesthesia. Internet J Anesthesiology study where emetic episodes were observed in 60% 2007; 13: 2. patients receiving ondansetron compared to 25% receiving 7. Sneader W. Drug Discovery: A History. John Wiley and granisetron and 90% in metoclopramide group. Sons, Ltd.: West Sussex, England, 2005. pp. 217 -19. Statistically granisetron was superior to ondansetron in 8. Rudra A. Comparison of ondansetron, metoclopramide and placebo in prevention of emetic episode following our study too. cholecystectomy.Pak J Anaesth1997; 14: 14-19. Kushwaha et al in 2007 (12) in their study concluded 9. Fujii Y, Tanaka M, Toyooka H. Clinical affect of that PONV was controlled better with granisetron granisetron, droperidal & metoclopramide in treatment of (incidence of PONV=16%) than with ondansetron post-operative nausea and vomiting after laparoscopic (incidence of PONV=28%). This result is also in cholecystectomy. Br J Surgery 2000; 87: 128 -30. accordance with our study. 10. Gigillo CA, Soares H, Castro CP. Granisetron is equivalent Conclusion to ondansetron for prophylaxis of chemotherapy induced. Nausea and Vomiting: Results of meta analysis of From the results of the study it can be safely concluded randomized control trial. Cancer 2000; 89: 01-08. that granisetron is much more effective than ondansetron 11. Bhattacharya D, Benerjee A. Comparison of ondansetron, in first 12 post operative hours and also that granisetron granisetron for PONV following day care gynecologist and ondansetron both are superior to metoclopramide for laparoscopy. Ind J Anaesthesia 2003; 4 : 279-82. prophylactic therapy for PONV. 12. Kushwaha bb, chakraborty a, agarwal j, malick a, References bhushan s, bhattacharya p. comparative study of 1. Knapp MR, Beecher HK. Post anaesthetic nausea, vomiting granisetron and ondansetron alone and their and retching: evaluation of anti-emetic drugs combination with dexamethasone, for prevention of , and pentobarbital sodium. ponv in middle ear surgery. Internet J Anesthesiology J Am Med Asso 1956; 160: 376-85 2007; ; 13 : 2.

Editorial Board proudly shares that JK Science, Journal of Medical Education & Research is now also under Indexing Coverage with MedLine LocatorPlus, IndexCopernicus International -IC Value 4.75(2007), Directory of Open Access Journals (DOAJ) ,OpenMed@NIC and many E-Indexing Agecies beside being indexed in Excerpta Medica EMBASE, Indian Science Abstract

Vol. 10 No. 2, April-June 2008 77