术后恶心呕吐的预防和治疗(英文)课件.ppt

Postoperative Nausea and Vomiting:Prevention and TreatmentPhillip E.Scuderi,M.D.Department of AnesthesiologyWake Forest University School of MedicineWinston-Salem,NC 27157-1009Postoperative Nausea and Vomiting:Prevention and TreatmentQuality of Clinical TrialsnAppearance of control treatmentnBlinding of randomization processnBlinding of patients and observers,nSample size estimate and power analysisnConfidence intervalsnStatistical analysesnWithdrawalsnSide effect discussionsGreenfield et al.Anesth Analg 2003;96:S88Quality of Clinical TrialsGreenfield et al.Anesth Analg 2003;96:S88Quality of Clinical TrialsnInvestigatorsnImprove rigor of study protocolsnImprove quality of data analysisnPeer ReviewersnProcess of randomizationnPower analysisnBlindingSuggestions for ImprovementGreenfield et al.Anesth Analg 2003;96:S88Critical Evaluation of DatanQuality of individual clinical trialsnEvaluation of data in aggregateEvidence Based MedicineRating ScaleLevel of evidence based on study designI.Large randomized,controlled trial(n100 per group)II.Systematic reviewIII.Small randomized,controlled trial(n100 per group)IV.Nonrandomized controlled trial or case reportV.Expert opinionStrength of Recommendation based on expert opinionA.Good evidence to support the recommendationB.Fair evidence to support the recommendationC.Insufficient evidence to recommend for or againstMeasures of Treatment ConsequencesRelative Risk ReductionnThe reduction of adverse events achieved by a treatment,expressed as a proportion of the control rateOdds RationThe traditional expression of the relative likelihood of an outcome expressed as P/(1-P)where P=probabilityAbsolute Risk ReductionnThe difference in event rates between the control and treatment groupsNumbers Needed to be Treated(NNT)nThe number of patients who must be treated in order to prevent one adverse event.It is mathematically equivalent to the reciprocal of the absolute risk reduction.Laupacis et al.NEJM 1988;318:1728-1733TopicsnRisk factorsnPharmacologic approaches to managementnAdjuvants(nonpharmacologic)nEfficacy versus outcomenPrevention versus treatmentnPostdischarge nausea and vomitingnMultimodal managementTopicsnRisk factorsRisk FactorsnAgenGendernBody habitusnHx motion sicknessnHx PONVnAnxietynConcomitant diseasenOperative procedurenDuration of surgeryNon-anesthetic FactorsRisk FactorsnPreanesthetic medicationnGastric distensionnGastric suctioningnAnesthetic techniquenAnesthetic agentsAnesthetic Related FactorsRisk FactorsnPainnDizzinessnAmbulationnOral intakenOpioidsPostoperative FactorsRisk FactorsPatient SpecificPalazzo M,Evans R.Logistic regression analysis of fixed patient factors for postoperative sickness:a model for risk assessment.Br J Anaesth 1993;70:135-40.Koivuranta M,Lr E,Snre L,Alahuhta S.A survey of postoperative nausea and vomiting.Anaesthesia 1997;52:443-49.Apfel CC,Greim CA,Haubitz I,et al.A risk score to predict the probability of postoperative vomiting in adults.Acta Anaesthesiol Scand 1998;42:495-501.Logistic RegressionRisk FactorsPatient SpecificnYounger age nNonsmoking history nFemale nHx of motion sickness nHx of PONV nIncreased duration of operation Logistic RegressionRisk FactorsAnesthetic RelatedRisk FactorsOR*CIVolatile anesthetics isoflurane3.412.18;5.37 sevoflurane2.781.79;4.31 enflurane3.111.98;4.88Apfel et al.BJA 2002;88:659-668*Compared to propofolVolatile Anesthetics Risk FactorsAnesthetic RelatedNitrous Oxide and PONV Risk FactorsAnesthetic RelatednDecreases POV significantly only if the baseline risk is highnDoes not affect nausea or complete control of emesisnIncreases the incidence of intraoperative awarenessOmitting nitrous oxide from general anesthesia:Tramer et al.BJA 1996;76:186-193Nitrous Oxide and PONV Evidence Based MedicineRisk Factors for PONV in AdultsPatient-specific factorsFemale gender(I-A)Nonsmoking status(IV-A)History of PONV/motion sickness(IV-A)Anesthetic risk factorsUse of volatile anesthetics(I-A)Nitrous oxide(II-A)Intraoperative opioids(II-A)Postoperative opioids(IV-A)Surgical risk factorsDuration of surgery(IV-A)Type of surgery(IV-B)Gan et al.et al.Anesth Analg 2003;97:62-71TopicsnRisk factorsnPharmacologic approaches to managementEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9*NNTPrevention of PONV:Ondansetron Versus PlaceboMcKenzie et al.Anesthesiology 1993;78:21-28All patients,0-24 hrs*p=0.010 p 8 mgNumbers Needed to be TreatedTramer et al.Anesthesiology 1997;87:1277-1289II-AEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9Ondansetron 1 mg-I-A-3.8 4.8*NNTTreatment of PONV:Ondansetron Versus PlaceboScuderi et al.Anesthesiology 1993;78:2-5Hantler et al.Anesthesiology 1992;77:A16*p 0.001I-AOndansetron Dose Response:Treatmentu All three doses significantly different than placebou No significant difference in antiemetic efficacy between the three doses of ondansetronNumbers Needed to be TreatedTramer et al.BMJ 1997;314:1088-1092II-AEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9Ondansetron 1 mg-I-A-3.8 4.8Dolasetron 12.5 mgI-AI-A4.0 5.03.6 4.2*NNTPrevention of PONV:Dolasetron Versus Placebo*p 0.0003 compared to placeboGraczyk et al.Anesth Analg 1997;84:325-330*I-ATreatment of PONV:Dolasetron Versus Placebo*p 0.001 compared to placeboKovac et al.Anesth Analg 1997;85:546-552*I-AEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9Ondansetron 1 mg-I-A-3.8 4.8Dolasetron 12.5 mgI-AI-A4.0 5.03.6 4.2Granisetron 1mgI-AI-A3.1 4.23.1 3.8*NNTPrevention of PONV:Granisetron Versus PlaceboWilson et al.BJA 1996;76:515-518*p 0.001 compared to placeboNo VomitingI-APrevention of PONV:Granisetron Versus PlaceboWilson et al.BJA 1996;76:515-518*p 0.001 compared to placeboNo NauseaI-APrevention of PONV:Granisetron Versus PlaceboWilson et al.BJA 1996;76:515-518*p 0.001 compared to placeboTotal ControlI-ATreatment of PONV:Granisetron Versus PlaceboTaylor et al.JCA.1997:9;658-663*p 0.001 compared to placeboNo VomitingI-ATreatment of PONV:Granisetron Versus PlaceboTaylor et al.JCA.1997:9;658-663*p 0.005 compared to placeboNo NauseaI-AEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9Ondansetron 1 mg-I-A-3.8 4.8Dolasetron 12.5 mgI-AI-A4.0 5.03.6 4.2Granisetron 1 mgI-AI-A3.1 4.23.1 3.8DroperidolI-A-4.3 5.0?*NNTPrevention of PONV:Ondansetron Versus DroperidolFortney et al.Anesth Analg 1998;86:731-738Complete Response*p 0.05 compared to placebo p 0.05 compared to ondansetron 4 mg p,0.05 compared to droperidol 0.625 mgI-APrevention of PONV:Ondansetron Versus DroperidolFortney et al.Anesth Analg 1998;86:731-738No Nausea*p 0.05 compared to placebo p 0.05 compared to droperidol 0.625 mg and ondansetron 4 mgI-AEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9Ondansetron 1 mg-I-A-3.8 4.8Dolasetron 12.5 mgI-AI-A4.0 5.03.6 4.2Granisetron 1 mgI-AI-A3.1 4.23.1 3.8DroperidolI-A-4.3 5.0?DexamethasoneII-A-4.3 7.1-*NNTPrevention of PONV:Dexamethasonen“In conclusion,in the surgical setting,a single prophylactic dose of dexamethasone is antiemetic compared with placebo without evidence of clinically relevant toxicity in otherwise healthy patients.Late efficacy(i.e.,Up to 24 hours)seems to be most pronounced.”Henzi I,Walder B,and Tramer,MR.Dexamethasone for the prevention of postoperative nausea and vomiting:a quantitative systematic review.Anesth Analg 2000;90:186-194Eberhart LH.Morin AM.Georgieff M.Dexamethasone for prophylaxis of postoperative nausea and vomiting.A meta-analysis of randomized controlled studies.Anaesthesist.2000;49:713-20II-AEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9Ondansetron 1 mg-I-A-3.8 4.8Dolasetron 12.5 mgI-AI-A4.0 5.03.6 4.2Granisetron 1 mgI-AI-A3.1 4.23.1 3.8DroperidolI-A-4.3 5.0?DexamethasoneII-A-4.3 7.1-DimenhydrinateII-AV-B4.8 8.0?*NNTPrevention of PONV:DimenhydrinateEarly(0-6 h)Overall(0-48 h)OutcomeTrialsNNTTrialsNNT PONV88.3165.0 Vomiting67.7144.8 Nausea28.375.9Kranke,et al.Acta Anaesth Scand 2002;46:238-244II-AEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9Ondansetron 1 mg-I-A-3.8 4.8Dolasetron 12.5 mgI-AI-A4.0 5.03.6 4.2Granisetron 1 mgI-AI-A3.1 4.23.1 3.8DroperidolI-A-4.3 5.0?DexamethasoneII-A-4.3 7.1-DimenhydrinateII-AV-B4.8 8.0?PromethazineIII-BV-B?*NNTPrevention of PONV:PromethazineKhalil et al.JCA 1999;11:596-600*p 0.05 compared to placeboNo VomitingIII-BPrevention of PONV:PromethazineKhalil et al.JCA 1999;11:596-600*p 0.05 compared to placeboNo Nausea*III-BPrevention of PONV:PromethazineKhalil et al.JCA 1999;11:596-600*p 0.05 compared to placeboTotal Response*III-BEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9Ondansetron 1 mg-I-A-3.8 4.8Dolasetron 12.5 mgI-AI-A4.0 5.03.6 4.2Granisetron 1 mgI-AI-A3.1 4.23.1 3.8DroperidolI-A-4.3 5.0?DexamethasoneII-A-4.3 7.1-DimenhydrinateII-AV-B4.8 8.0?PromethazineIII-BV-B?Metoclopramide-V-B?*NNTPrevention of PONV:Metoclopramiden“In summary,metoclopramide,although used as an antiemetic for almost 40 years in the prevention of PONV,has no clinically relevant antiemetic effect.it is very likely that the doses used in daily clinical practice are too low.”Henzi I,Walder B,and Tramer,MR.Metoclopramide in the prevention of postoperative nausea and vomiting:a quantitative systematic review of randomized,placebo-controlled studies.BJA 1999;83:761-771II-AEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9Ondansetron 1 mg-I-A-3.8 4.8Dolasetron 12.5 mgI-AI-A4.0 5.03.6 4.2Granisetron 1 mgI-AI-A3.1 4.23.1 3.8DroperidolI-A-4.3 5.0?DexamethasoneII-A-4.3 7.1-DimenhydrinateII-AV-B4.8 8.0?PromethazineIII-BV-B?Metoclopramide-V-B-?Scopolamine patchII-B-5.0 7.0?*NNTPrevention of PONV:ScopolamineSmall StudiesLarge StudiesOutcomeTrialsNNTTrialsNNT Vomiting 63.355.9 Nausea25.355.0 PONV82.986.7 Rescue43.837.0Kranke,et al.Anesth Analg 2002;95:133-143Defined control event rateII-APrevention of PONV:ScopolamineEventNNH Visual disturbances5.6 Dry mouth12.5 Dizziness50.0 Agitation100.1Kranke,et al.Anesth Analg 2002;95:133-143Adverse EventsII-AEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndansetron 4 mgI-AI-A5.5 6.53.2 3.9Ondansetron 1 mg-I-A-3.8 4.8Dolasetron 12.5 mgI-AI-A4.0 5.03.6 4.2Granisetron 1 mgI-AI-A3.1 4.23.1 3.8DroperidolI-A-4.3 5.0?DexamethasoneII-A-4.3 7.1-DimenhydrinateII-AV-B4.8 8.0?PromethazineIII-BV-B?Metoclopramide-V-B-?Scopolamine patchII-B-5.0 7.0?*NNTPrevention of PONV:Combination TherapynMcKenzie R,et al.Comparison of ondansetron with ondansetron plus dexamethasone in the prevention of postoperative nausea and vomiting.Anesth Analg 1994;79:961-964nLopez-Olaondo L,et al.Combination of ondansetron and dexamethasone in the prophylaxis of postoperative nausea and vomiting.BJA 1996;76:835-840nEberhart LH.Morin AM.Georgieff M.Dexamethasone for prophylaxis of postoperative nausea and vomiting.A meta-analysis of randomized controlled studies.Anaesthetist.2000;49:713-20(meta analysis)Ondansetron/Dexamethasone III-APrevention of PONV:Combination TherapynPueyo FJ,et al.Combination of ondansetron and droperidol in the prophylaxis of postoperative nausea and vomiting.Anesth Analg 1996;83:117-122nMcKenzie R,et al.Droperidol/ondansetron combination controls nausea and vomiting after tubal banding.Anesth Analg 1996;83:1218-1222nKlockgether-Radke A,et al.Ondansetron,droperidol and their combination for the prevention of post-operative vomiting in children.Eur J Anesthesiology.1997;14:362-367nEberhart LH.Morin AM.Bothner U.Georgieff M.Droperidol and 5HT3-receptor antagonists,alone or in combination,for prophylaxis of postoperative nausea and vomiting.A meta-analysis of randomized controlled trials.Acta Anaesthesiologica scandinavica.2000;44:1252-7Ondansetron/Droperidol III-APrevention of PONV:Combination TherapyWhich Combination?Event5-HT3+drop5-HT3+dexNRateNRateP-valueOREarly Nausea13817%26011%0.121.6 Vomiting3181%4191%1.001.0Late Nausea35827%62321%*0.021.4 Vomiting4439%8139%1.000.9Ashraf et al.Anesthesiology 2001;95:A-41Prevention of PONV:Timing of AdministrationnSun et al.The effect of timing on ondansetron administration in outpatients undergoing otolaryngologic surgery.Anesth Analg 1997;84:331-336nChen et al.The effect of timing of dolasetron administration on its efficacy as a prophylactic antiemetic in the ambulatory setting.Anesth Analg 2001;93:906-911nWang et al.The effect of timing of dexamethasone administration on its efficacy as a prophylactic antiemetic for postoperative nausea and vomiting.Anesth Analg 2000;91;136-139Ondansetron III-ADexamethasone III-ADolasetron III-ABreakthrough PONV:Repeat Dosing With OndansetronKovac et al.J.Clin Anesth 1999;11:453-459*p=0.074 p=0.342I-ATopicsnRisk factorsnPharmacologic approaches to managementnAdjuvants(nonpharmacologic)Management of PONV:Adjuvants(Nonpharmacologic)nP-6 acupuncture point stimulation III-AnSupplemental oxygen III-CnAggressive perioperative rehydration III-AnPreemptive analgesia IV-ATopicsnRisk factorsnPharmacologic approaches to managementnAdjuvants(nonpharmacologic)nEfficacy versus outcomeEfficacy Versus OutcomeIf efficacy alone is an appropriate endpoint when evaluating analgesics,why isnt efficacy a valid endpoint when evaluating antiemetics?TopicsnRisk factorsnPharmacologic approaches to managementnAdjuvants(nonpharmacologic)nEfficacy versus outcomenPrevention versus treatmentPrevention versus TreatmentFrequency of PACU Treatment by Risk Factors and GroupScuderi et al.Anesthesiology.1999;90:360-371Prevention Versus TreatmentRoutine administration of prophylactic antiemetics does reduce the incidence of emesis both before and after discharge;however,it did not improve any of the measures of outcome following outpatient surgery except in patients at the highest risk for symptoms.Scuderi et al.Anesthesiology.1999;90:360-371IA,IIIATopicsnRisk factorsnPharmacologic approaches to managementnAdjuvants(nonpharmacologic)nEfficacy versus outcomenPrevention versus treatmentnPostdischarge nausea and vomitingPost Discharge Symptoms Following Ambulatory SurgerySymptomIncidence(%)Pain45Nausea17Vomiting8Headache17Drowsiness42Dizziness18Fatigue21Wu CL,et al.Anesthesiology 2002;96:994-1003Postdischarge Vomiting:Ondansetr