Ⅵ CLINICAL INVESTIGATIONS Anesthesiology 2003; 98:293–8 © 2003 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Antiemetic Prophylaxis for Office-based Surgery Are the 5-HT3 Receptor Antagonists Beneficial? Jun Tang, M.D.,* Xiaoguang Chen, M.D.,* Paul F. White, Ph.D., M.D., F.A.N.Z.C.A.,† Ronald H. Wender, M.D.,‡ Hong Ma, M.D., Ph.D.,* Alexander Sloninsky, M.D.,§ Robert Naruse, M.D.,§ Robert Kariger, M.D.,§ Tom Webb, M.D.,§ Alan Zaentz, M.D.§ Background: Office-based surgery has become increasingly quirement for rescue antiemetics were also similar in all three popular because of its cost-saving potential. However, the oc- groups during the 24-h study period. In addition, the complete currence of postoperative nausea and vomiting (PONV) can response rates to the prophylactic antiemetics (96–98%) and Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/98/2/293/336469/0000542-200302000-00005.pdf by guest on 01 October 2021 delay patient discharge. Prophylaxis using a combination of percentages of very satisfied patients (93–98%) were equally antiemetic drugs has been suggested as an effective strategy for high in all three groups. However, the antiemetic drug acquisi- minimizing PONV. The authors designed this randomized, dou- tion costs were US $2.50, $15.50, and $18.50 in the control, ble-blinded, placebo-controlled study to assess the efficacy of dolasetron, and ondansetron groups, respectively. ondansetron and dolasetron when administered in combina- Conclusion: The addition of dolasetron (12.5 mg) or ondan- tion with droperidol and dexamethasone for routine antiemetic setron (4 mg) failed to improve the antiemetic efficacy of prophylaxis against PONV in the office-based surgery setting. droperidol (0.625 mg intravenous) and dexamethasone (4 mg Methods: Following institutional review board approval, 135 intravenous) when they were used for routine prophylaxis in consenting outpatients with American Society of Anesthesiolo- the office-based surgery setting. gists physical status I–III who were undergoing superficial sur- gical procedures lasting 20–40 min were randomly assigned to one of three antiemetic treatment groups. Propofol was admin- BECAUSE of its cost-saving potential,1 office-based sur- istered for induction of anesthesia, followed by 2–4% desflu- gery is expected to continue to grow in the United rane with 67% nitrous oxide in oxygen. Desflurane was subse- States.2 Anesthetic techniques used in the office-based quently adjusted to maintain a clinically adequate depth of anesthesia with an electroencephalographic Bispectral Index setting should be safe, effective, and associated with a 3 value between 50 and 60. All patients received 0.625 mg intra- rapid recovery. Nausea and vomiting after ambulatory venous droperidol and 4 mg intravenous dexamethasone after surgery remains a major problem4 and has been found induction of anesthesia. The study medication, containing nor- to prolong the time to discharge after office-based mal saline (control), 12.5 mg intravenous dolasetron, or 4 mg 5 intravenous ondansetron, was administered prior to the end of surgery. Postoperative nausea and vomiting (PONV) surgery. All patients received local anesthetics at the incisional has also been demonstrated to reduce patient satisfac- site and 30 mg intravenous ketolorac to minimize postoperative tion in the office-based setting.5 As a result, White and pain. Recovery profiles, incidence of PONV, requirement for Watcha6 have recommended routine antiemetic pro- rescue antiemetic drugs, complete response rates, and patient phylaxis of outpatient populations at increased risk of satisfaction were assessed. Results: The recovery times to patient orientation, oral in- developing PONV. take, ambulation, and actual discharge did not differ among the Since the causes of PONV are multifactorial, with at three groups. The incidence of PONV, nausea scores, and re- least four different neurotransmitter systems implicated in the etiology of PONV,7 no single antiemetic drug possesses the ability to prevent PONV in all patient This article is accompanied by an Editorial View. Please see ᭜ Scuderi PE: Droperidol: Many questions, few answers. ANES- populations. Therefore, combination antiemetic therapy THESIOLOGY 2003;98:289–90. using drugs that act at different neuroreceptor sites has been recommended for the at-risk patient.8 Recently, Scuderi et al.9 demonstrated that multimodal manage- * Clinical Research Fellow, † Professor and Holder of the Margaret Milam ment with a combination of three antiemetic drugs was McDermott Distinguished Chair in Anesthesiology, University of Texas South- western Medical Center at Dallas. ‡ Clinical Professor, Department of Anesthe- superior to single-drug therapy in preventing PONV. In siology, University of California-Irvine, and Co-Chief of Anesthesia, Cedars-Sinai an earlier study, we found that antiemetic prophylaxis Medical Center, Los Angeles, California. § Staff Anesthesiologist, Cedars-Sinai Medical Center, Los Angeles, California. with a combination of droperidol, ondansetron, and met- Received from the Department of Anesthesiology and Pain Management, oclopramide was highly effective in minimizing PONV University of Texas Southwestern Medical Center at Dallas, Dallas, Texas. after office-based surgery with a desflurane-based anes- Submitted for publication June 17, 2002. Accepted for publication September 6, 10 2002. The clinical research fellowships were supported by departmental re- thetic technique. sources. This study was also supported by the White Mountain Institute, a A recent meta-analysis suggested that combining not-for-profit private foundation in Los Altos, California (Dr. White is the presi- dent). Dr. White has received funding and honoraria in the past from Abbott dexamethasone with a 5-HT3 receptor antagonist pro- Laboratories, Chicago, Illinois, and GlaxoSmithKline laboratories, Research Tri- vided greater antiemetic efficacy, and this combina- angle Park, North Carolina. tion therapy was recommended as the “optimal” Address reprint requests to Dr. White: Department of Anesthesiology and Pain 11 Management, University of Texas Southwestern Medical Center, 5323 Harry choice for prophylaxis against PONV. Another meta- Hines Boulevard, F2.208, Dallas, Texas 75390-9068. Address electronic mail to: analysis reported that dexamethasone also enhanced [email protected]. Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org. the antiemetic efficacy of other antiemetics (e.g., do- Anesthesiology, V 98, No 2, Feb 2003 293 294 TANG ET AL. pamine antagonists) when administered as part of a laryngeal mask airway, and local anesthetic (consisting combination therapy.12 Therefore, we designed a of a mixture of 2% lidocaine and 0.5% bupivacaine) was study to test the hypothesis that adding a 5-HT3 recep- injected at the incision site by the surgeon for intraop- tor antagonist would improve the ability of dexameth- erative and postoperative analgesia. Ketorolac, 30 mg asone and droperidol to prevent PONV after office- intravenous, was also administered during surgery to based surgery. minimize postoperative pain. Droperidol, 0.625 mg in- travenous, and dexamethasone, 4 mg intravenous, were administered to all patients after induction of anesthesia. Materials and Methods The study medications were prepared by the local phar- macy in identical-appearing 5-ml syringes containing After obtaining institutional review board approval at saline (control), dolasetron (12.5 mg), or ondansetron Cedars-Sinai Medical Center (Los Angeles, CA) and writ- (4 mg) and were administered intravenously 10–15 min Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/98/2/293/336469/0000542-200302000-00005.pdf by guest on 01 October 2021 ten informed consent, 135 outpatients with American prior to the end of surgery. The maintenance anesthetics Society of Anesthesiologists physical status I–III who were discontinued at the start of skin closure. On awak- were undergoing superficial surgical procedures lasting ening from anesthesia, the patients’ abilities to meet 20–40 min were enrolled in this placebo-controlled, specific fast-track discharge criteria were assessed at double-blinded study. Patients were randomly assigned 2-min intervals.13 After applying the surgical dressing, to one of three study groups according to a computer- the patients were asked to sit up on the operating room generated random numbers table. The groups comprised table. After standing up, they were allowed to walk to the following: (1) control (saline), (2) dolasetron (12.5 mg), the recovery area with assistance. and (3) ondansetron (4 mg). The study was performed at a Anesthesia time (from induction of anesthesia to dis- private office-based surgical center (Bedford Surgicenter, continuation of nitrous oxide) and surgery time (from Beverly Hills, California) with a single operating room and incision to placement of the dressing) were recorded. one recovery bed. Exclusion criteria included pregnancy; The times at which patients were able to open their active menstruation; body weight more than 50% above the eyes, were able to follow commands (e.g., squeeze the ideal body weight; vomiting or retching within 24 h before investigator’s hand), and were oriented to their name the operation; administration of antiemetic or psychoactive and their place and date of birth were assessed by a medication within 24 h before surgery; a previous history blinded observer at 1-min