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Previous Volume 350:2441-2451 June 10, 2004 Number 24 Next

	Full Text PDF PDA Full Text PowerPoint Slide Set Supplementary Material Editorial by White, P. F. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background Untreated, one third of patients who undergo surgery will have postoperative nausea and vomiting. Although many trials have been conducted, the relative benefits of prophylactic antiemetic interventions given alone or in combination remain unknown.

Methods We enrolled 5199 patients at high risk for postoperative nausea and vomiting in a randomized, controlled trial of factorial design that was powered to evaluate interactions among as many as three antiemetic interventions. Of these patients, 4123 were randomly assigned to 1 of 64 possible combinations of six prophylactic interventions: 4 mg of ondansetron or no ondansetron; 4 mg of dexamethasone or no dexamethasone; 1.25 mg of droperidol or no droperidol; propofol or a volatile anesthetic; nitrogen or nitrous oxide; and remifentanil or fentanyl. The remaining patients were randomly assigned with respect to the first four interventions. The primary outcome was nausea and vomiting within 24 hours after surgery, which was evaluated blindly.

Results Ondansetron, dexamethasone, and droperidol each reduced the risk of postoperative nausea and vomiting by about 26 percent. Propofol reduced the risk by 19 percent, and nitrogen by 12 percent; the risk reduction with both of these agents (i.e., total intravenous anesthesia) was thus similar to that observed with each of the antiemetics. All the interventions acted independently of one another and independently of the patients' baseline risk. Consequently, the relative risks associated with the combined interventions could be estimated by multiplying the relative risks associated with each intervention. Absolute risk reduction, though, was a critical function of patients' baseline risk.

Conclusions Because antiemetic interventions are similarly effective and act independently, the safest or least expensive should be used first. Prophylaxis is rarely warranted in low-risk patients, moderate-risk patients may benefit from a single intervention, and multiple interventions should be reserved for high-risk patients.

Source Information

From Julius-Maximilians Universität, Würzburg, Germany (C.C.A., M.K., N.R.); the University of Louisville, Louisville, Ky. (C.C.A., D.I.S.); Helsinki University Central Hospital, Helsinki, Finland (K.K., R.J.); the London School of Hygiene and Tropical Medicine, London (M.A., S.J.P.); the Universitätsklinik Mannheim, Mannheim, Germany (H.K.); Trakya University Hospital, Edirne, Turkey (A.T.); von Bodelschwingsche Anstalten Bethel, Bielefeld, Germany (I.V.); Kreiskrankenhaus Garmisch-Partenkirchen, Garmisch-Partenkirchen, Germany (C.Z.); Westpfalz-Klinikum, Kaiserslautern, Germany (K.D.); Reiman University Hospital, Presov, Slovakia (S.T.); and the Universitätskliniken des Saarlandes, Homburg, Germany (A.B.).

Address reprint requests to Dr. Apfel at Outcomes Research Institute, 501 East Broadway, Suite 210, Louisville, KY 40202, or at apfel{at}ponv.org.

Full Text of this Article

Related Letters:

Prevention of Postoperative Nausea and Vomiting
Yalçn S., Yalçn B., Büyükçelik A., Hartig F., Pechlaner C., Apfel C. C., Sessler D. I.
Extract | Full Text | PDF  
N Engl J Med 2004; 351:1458-1459, Sep 30, 2004. Correspondence

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