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1、Postoperative Nausea and Vomiting: Prevention and TreatmentPhillip E. Scuderi, M.D. Department of Anesthesiology Wake Forest University School of Medicine Winston-Salem, NC 27157-1009Postoperative Nausea and Vomiting: Prevention and Treatmenthttp:/www.wfubmc.edu/anesthesia pscuderiwfubmc.eduHistoric
2、al Perspective on PONVPostoperative Nausea and Vomiting:Its Etiology, Treatment, and PreventionMehernoor F. Watcha and Paul F. WhiteAnesthesiology 1992;77:162-184Quality of Clinical TrialsnAppearance of control treatmentnBlinding of randomization processnBlinding of patients and observers,nSample si
3、ze 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
4、quality of data analysisnPeer ReviewersnProcess of randomizationnPower analysisnBlindingSuggestions for ImprovementGreenfield et al. Anesth Analg 2003;96:S88Critical Evaluation of DatanQuality of individual clinical trialsnType and adequacy of controls usednBlinding processnSample size, power analys
5、isnAppropriateness of endpoints chosennConfidence limits particularly for negative studiesnStatistical analysisCritical Evaluation of DatanQuality of individual clinical trialsnEvaluation of data in aggregateEvidence Based Medicine Rating ScaleLevel of evidence based on study designI. Large randomiz
6、ed, controlled trial (n100 per group)II. Systematic review III. Small randomized, controlled trial (n8 mgNumbers Needed to be TreatedTramer et al. Anesthesiology 1997;87:1277-1289II-AEvidence Rating for AntiemeticsStrength of EvidenceTreatment Consequences*PreventionTreatmentPreventionTreatmentOndan
7、setron 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;78:2-5 Hantler et al. Anesthesiology 1992;77:A16* * p 0.001I-AOndansetron Dose Response: Treatmentu All three doses significantly different than placebo u No
8、 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.
9、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 placebo Graczyk et al. Anesth Analg 1997;84:325-330* *I-ATreatment of PONV: Dolasetron Versus Placebo*p 0.001 compared to placebo Kovac et al. Anesth Analg 1997;8
10、5:546-552*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 Ve
11、rsus 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 compar
12、ed to placeboTotal ControlI-ATreatment of PONV: Granisetron Versus PlaceboTaylor et al. JCA. 1997:9;658-663*p 0.001 compared to placeboNo Vomiting I-ATreatment of PONV: Granisetron Versus PlaceboTaylor et al. JCA. 1997:9;658-663*p 0.005 compared to placeboNo NauseaI-AEvidence Rating for AntiemeticsS
13、trength 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
14、 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
15、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.
16、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
