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Christian C Apfel - One of the best experts on this subject based on the ideXlab platform.
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intravenous acetaminophen reduces Postoperative nausea and Vomiting a systematic review and meta analysis
Pain, 2013Co-Authors: Christian C Apfel, Joseph V Pergolizzi, Alparslan Turan, Kimberly Souza, Cyrill HornussAbstract:Abstract Opioids are a key risk factor for Postoperative nausea and Vomiting (PONV). As intravenous (i.v.) acetaminophen reduces Postoperative pain and opioid requirements, one would expect i.v. acetaminophen to be associated with a lower incidence of opioid-induced side effects, including PONV. We conducted a systematic search using Medline and Cochrane databases supplemented with hand search of abstract proceedings to identify randomized-controlled trials of i.v. acetaminophen. Inclusion criteria were (a) randomized for i.v. acetaminophen vs a placebo control, (b) general anesthesia, and (c) reported or obtainable PONV outcomes. Primary outcome was Postoperative nausea and secondary outcome was Postoperative Vomiting. We included 30 studies with 2364 patients (1223 in the acetaminophen group, 1141 in the placebo group). The relative risk (95% confidence interval) was 0.73 (0.60–0.88) for nausea and 0.63 (0.45–0.88) for Vomiting. Data showed significant heterogeneity for both nausea (P = 0.02, I2 = 38%) and Vomiting (P = 0.006, I2 = 47%), but were homogeneous when studies were grouped according to timing of first administration: i.v. acetaminophen reduced nausea when given prophylactically either before surgery, 0.54 (0.40–0.74), or before arrival in the postanesthesia care unit, 0.67 (0.55–0.83); but not when given after the onset of pain, 1.12 (0.85–1.48). When i.v. acetaminophen was given prophylactically, the reduction of nausea correlated with the reduction of pain (odds ratio 0.66, 0.47–0.93), but not with reduction in Postoperative opioids (odds ratio 0.89, 0.64–1.22). Prophylactically administered i.v. acetaminophen reduced PONV, mainly mediated through superior pain control.
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supplemental intravenous crystalloids for the prevention of Postoperative nausea and Vomiting quantitative review
BJA: British Journal of Anaesthesia, 2012Co-Authors: Christian C Apfel, A Meyer, Mukadder Orhansungur, Leena Jalota, R P Whelan, S JukarraoAbstract:Postoperative Vomiting (POV) (0.66, 0.37 –1.16; P¼0.16) or late POV (0.52, 0.25 –1.11; P¼0.09), but did reduce overall POV (0.48, 0.29– 0.79; P¼0.004). I.V. crystalloids did not reduce the risk of early PONV (0.74, 0.49– 1.12; P¼0.16), but did reduce the risk of late PONV (0.27, 0.13–0.54; P,0.001) and overall PONV (0.59, 0.42 –0.84; P¼0.003). I.V. crystalloids reduced the need for antiemetic rescue treatment (0.56, 0.45–0.68; P,0.001). In summary, supplemental i.v. crystalloids were associated with a lower incidence of several PONV outcomes. However, a number of PONV outcomes failed to reach statistical significance, perhaps due to the lack of power. Thus, studies sufficiently powered for the less frequent outcomes (e.g. POV) are required.
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preventing Postoperative nausea and Vomiting post hoc analysis of pooled data from two randomized active controlled trials of aprepitant
Current Medical Research and Opinion, 2007Co-Authors: Pierre Diemunsch, Beverly K Philip, Tong J Gan, Christian C Apfel, Keith A Candiotti, Jacques E Chelly, Alexandra D Carides, Judith K Evans, Theodore F ReissAbstract:ABSTRACTObjective: Compared with the 5HT3 antagonist ondansetron, the NK1 antagonist aprepitant has been shown in two double-blind trials to provide greater protection against Postoperative Vomiting and comparable or greater control of nausea. Post hoc analyses of pooled data from these trials were performed to more fully characterize the efficacy profile of aprepitant in terms of nausea and use of rescue therapy.Research design and methods: Patients (n = 1599) scheduled for major surgery under general anesthesia (primarily gynecological surgery) were assigned to receive a preoperative dose of aprepitant 40 mg PO, 125 mg PO, or ondansetron 4 mg IV. in two randomized, double-blind, clinical trials.Main outcome measures: Post-surgery Vomiting episodes, use of rescue therapy, and nausea severity (verbal rating scale).Results: In the 24 hours after surgery, aprepitant 40 mg was more effective than ondansetron for all five endpoints evaluated: (1) no significant nausea (56.4% vs. 48.1%); (2) no nausea (39.6% v...
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volatile anaesthetics may be the main cause of early but not delayed Postoperative Vomiting a randomized controlled trial of factorial design
BJA: British Journal of Anaesthesia, 2002Co-Authors: Christian C Apfel, Peter Kranke, M H Katz, C Goepfert, T Papenfuss, Scott L Rauch, R Heineck, C A Greim, Norbert RoewerAbstract:Background Despite intensive research, the main causes of Postoperative nausea and Vomiting (PONV) remain unclear. We sought to quantify the relative importance of operative, anaesthetic and patient-specific risk factors to the development of PONV. Methods We conducted a randomized controlled trial of 1180 children and adults at high risk for PONV scheduled for elective surgery. Using a five-way factorial design, we randomly assigned subjects by gender who were undergoing specific operative procedures, to receive various combinations of anaesthetics, opioids, and prophylactic antiemetics. Results Of the 1180 patients, 355 (30.1% 95% CI (27.5–32.7%)) had at least one episode of Postoperative Vomiting (PV) within 24 h post-anaesthesia. In the early Postoperative period (0–2 h), the leading risk factor for Vomiting was the use of volatile anaesthetics, with similar odds ratios (OR (95% CI)) being found for isoflurane (19.8 (7.7–51.2)), enflurane (16.1 (6.2–41.8)) and sevoflurane (14.5 (5.6–37.4)). A dose–response relationship was present for the use of volatile anaesthetics. In contrast, no dose response existed for propofol anaesthesia. In the delayed Postoperative period (2–24 h), the main predictors were being a child (5.7 (3.0–10.9)), PONV in the early period (3.4 (2.4–4.7)) and the use of Postoperative opioids (2.5 (1.7–3.7)). The influence of the antiemetics was considerably smaller and did not interact with anaesthetic or surgical variables. Conclusion Volatile anaesthetics were the leading cause of early Postoperative Vomiting. The pro-emetic effect was larger than other risk factors. In patients at high risk for PONV, it would therefore make better sense to avoid inhalational anaesthesia rather than simply to add an antiemetic, which may still be needed to prevent or treat delayed Vomiting.
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a risk score to predict the probability of Postoperative Vomiting in adults
Acta Anaesthesiologica Scandinavica, 1998Co-Authors: Christian C Apfel, C Goepfert, C A Greim, I Haubitz, J Usadel, P Sefrin, Norbert RoewerAbstract:Background: The aim of this study was to identify factors most relevant for Postoperative Vomiting (PV) and to develop a risk score to predict the probability of PV. Methods: Adult inpatients scheduled for elective ear, nose and throat (ENT) surgery under general anaesthesia were offered to participate in a prospective study for PV over 24 h. No prophylactic antiemetics were used. The data of 1137 patients were randomized and split into an evaluation set (n=553) and a validation set (n=584). The evaluation set was subjected to logistic regression analysis to quantify the relative impact of anaesthetic, surgical and individual factors and to develop a risk score. The score was then tested by applying it to the validation set. The area under a receiver operation characteristic (ROC) curve was calculated and the predicted and actual incidences of patients were correlated. Results: In the evaluation set, patient-related factors (female gender, young age, non-smoking, history of PV or motion sickness) and a high duration of anaesthesia were independent risk factors for PV. The probability of PV could be estimated from the equation: PV=1/(1+exp(-z)) where z=1.28.(gender)-0.029 (age)-0.74 (smoking)+0.63 . (history of PV or motion sickness) +0.26 . (duration)-0.92. In the validation set this score achieved an area under the ROC-curve of 0.78 and the actual incidence correlated strongly with the predicted risks (R 2 =0.93, P<0.001). Conclusion: The data suggest that the probability of PV following ENT surgery under inhalational anaesthesia with low-dose opioids can be predicted by a score mainly based upon patient-related risk factors.
Norbert Roewer - One of the best experts on this subject based on the ideXlab platform.
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the efficacy and safety of transdermal scopolamine for the prevention of Postoperative nausea and Vomiting a quantitative systematic review
Anesthesia & Analgesia, 2002Co-Authors: Peter Kranke, A M Morin, Norbert Roewer, H Wulf, L H J EberhartAbstract:UNLABELLED The role of scopolamine administered via transdermal therapeutic systems in the prevention of Postoperative Vomiting, nausea, and nausea and Vomiting is unclear. We performed a systematic search for full reports of randomized comparisons of transdermal scopolamine with inactive control. Dichotomous data were extracted. In the meta-analysis, relative risks and numbers-needed-to-treat/harm were calculated with 95% confidence intervals (CI). In 23 trials, 979 patients received transdermal scopolamine, and 984 patients received placebo. Sensitivity analyses were performed using restricted data for truncated control event rates (40%-80%) and for large trials. With these data, the relative risks for Postoperative Vomiting (five reports), nausea (five reports), nausea and Vomiting (eight reports), and rescue treatment (three reports) were 0.69 (95% CI, 0.58-0.82), 0.69 (95% CI, 0.54-0.87), 0.76 (95% CI, 0.66-0.88), and 0.68 (95% CI, 0.54-0.85), respectively. This means that of 100 patients who receive transdermal scopolamine, approximately 17 will not experience Postoperative Vomiting who would have done so had they all received a placebo. However, 18 of 100 patients will have visual disturbances, eight will report dry mouth, two will report dizziness, one will be classified as being agitated, and 1-13 patients who are prescribed transdermal scopolamine will not use it correctly. The timing of application does not alter efficacy. IMPLICATIONS Of 100 patients who receive transdermal scopolamine, approximately 17 will not vomit in the Postoperative period who would have done so had they all received a placebo. However, 18 of 100 patients will have visual disturbances, and eight will report dry mouth. Incorrect use further limits its efficacy.
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volatile anaesthetics may be the main cause of early but not delayed Postoperative Vomiting a randomized controlled trial of factorial design
BJA: British Journal of Anaesthesia, 2002Co-Authors: Christian C Apfel, Peter Kranke, M H Katz, C Goepfert, T Papenfuss, Scott L Rauch, R Heineck, C A Greim, Norbert RoewerAbstract:Background Despite intensive research, the main causes of Postoperative nausea and Vomiting (PONV) remain unclear. We sought to quantify the relative importance of operative, anaesthetic and patient-specific risk factors to the development of PONV. Methods We conducted a randomized controlled trial of 1180 children and adults at high risk for PONV scheduled for elective surgery. Using a five-way factorial design, we randomly assigned subjects by gender who were undergoing specific operative procedures, to receive various combinations of anaesthetics, opioids, and prophylactic antiemetics. Results Of the 1180 patients, 355 (30.1% 95% CI (27.5–32.7%)) had at least one episode of Postoperative Vomiting (PV) within 24 h post-anaesthesia. In the early Postoperative period (0–2 h), the leading risk factor for Vomiting was the use of volatile anaesthetics, with similar odds ratios (OR (95% CI)) being found for isoflurane (19.8 (7.7–51.2)), enflurane (16.1 (6.2–41.8)) and sevoflurane (14.5 (5.6–37.4)). A dose–response relationship was present for the use of volatile anaesthetics. In contrast, no dose response existed for propofol anaesthesia. In the delayed Postoperative period (2–24 h), the main predictors were being a child (5.7 (3.0–10.9)), PONV in the early period (3.4 (2.4–4.7)) and the use of Postoperative opioids (2.5 (1.7–3.7)). The influence of the antiemetics was considerably smaller and did not interact with anaesthetic or surgical variables. Conclusion Volatile anaesthetics were the leading cause of early Postoperative Vomiting. The pro-emetic effect was larger than other risk factors. In patients at high risk for PONV, it would therefore make better sense to avoid inhalational anaesthesia rather than simply to add an antiemetic, which may still be needed to prevent or treat delayed Vomiting.
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a risk score to predict the probability of Postoperative Vomiting in adults
Acta Anaesthesiologica Scandinavica, 1998Co-Authors: Christian C Apfel, C Goepfert, C A Greim, I Haubitz, J Usadel, P Sefrin, Norbert RoewerAbstract:Background: The aim of this study was to identify factors most relevant for Postoperative Vomiting (PV) and to develop a risk score to predict the probability of PV. Methods: Adult inpatients scheduled for elective ear, nose and throat (ENT) surgery under general anaesthesia were offered to participate in a prospective study for PV over 24 h. No prophylactic antiemetics were used. The data of 1137 patients were randomized and split into an evaluation set (n=553) and a validation set (n=584). The evaluation set was subjected to logistic regression analysis to quantify the relative impact of anaesthetic, surgical and individual factors and to develop a risk score. The score was then tested by applying it to the validation set. The area under a receiver operation characteristic (ROC) curve was calculated and the predicted and actual incidences of patients were correlated. Results: In the evaluation set, patient-related factors (female gender, young age, non-smoking, history of PV or motion sickness) and a high duration of anaesthesia were independent risk factors for PV. The probability of PV could be estimated from the equation: PV=1/(1+exp(-z)) where z=1.28.(gender)-0.029 (age)-0.74 (smoking)+0.63 . (history of PV or motion sickness) +0.26 . (duration)-0.92. In the validation set this score achieved an area under the ROC-curve of 0.78 and the actual incidence correlated strongly with the predicted risks (R 2 =0.93, P<0.001). Conclusion: The data suggest that the probability of PV following ENT surgery under inhalational anaesthesia with low-dose opioids can be predicted by a score mainly based upon patient-related risk factors.
L H J Eberhart - One of the best experts on this subject based on the ideXlab platform.
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the development and validation of a risk score to predict the probability of Postoperative Vomiting in pediatric patients
Anesthesia & Analgesia, 2004Co-Authors: L H J Eberhart, Peter Kranke, A M Morin, G Geldner, A Schauffelen, H Treiber, H WulfAbstract:Risk scores to predict the occurrence of Postoperative Vomiting (PV) or nausea and Vomiting that were developed for adult patients do not fit for children, because several risk factors are difficult to assess or are usually not applicable in pediatric patients (e.g., smoking status). Thus, in the present study, we sought to develop and to validate a simple score to predict PV in children (POVOC-score). Development and validation of the new score was based on data from 4 independent institutions of 1257 children (aged 0-14 yr) undergoing various types of surgery under general anesthesia without antiemetic prophylaxis. Preoperatively, several potential risk factors were recorded. Postoperatively, the occurrence of PV was observed for up to 24 h. The dataset was randomly split into an evaluation set (n = 657) that was analyzed using a forward logistic regression technique and a validation set (n = 600) that was used to confirm the accuracy of prediction by means of the area under a receiver operating characteristic curve. Four independent risk factors for PV were identified in the final analysis: duration of surgery >/=30 min, age >/=3 yr, strabismus surgery, and a positive history of PV in the children or PV/Postoperative nausea and Vomiting in relatives (mother, father, or siblings). The incidence of PV was 9%, 10%, 30%, 55%, and 70% for 0, 1, 2, 3, and 4 risk factors observed. Using these incidences as cut-off values in the validation dataset, the area under the receiver operating characteristic curve was 0.72 (95% confidence interval: 0.68-0.77). Our data suggest that PV can be predicted with an acceptable accuracy using a four-item simplified risk score.
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the efficacy and safety of transdermal scopolamine for the prevention of Postoperative nausea and Vomiting a quantitative systematic review
Anesthesia & Analgesia, 2002Co-Authors: Peter Kranke, A M Morin, Norbert Roewer, H Wulf, L H J EberhartAbstract:UNLABELLED The role of scopolamine administered via transdermal therapeutic systems in the prevention of Postoperative Vomiting, nausea, and nausea and Vomiting is unclear. We performed a systematic search for full reports of randomized comparisons of transdermal scopolamine with inactive control. Dichotomous data were extracted. In the meta-analysis, relative risks and numbers-needed-to-treat/harm were calculated with 95% confidence intervals (CI). In 23 trials, 979 patients received transdermal scopolamine, and 984 patients received placebo. Sensitivity analyses were performed using restricted data for truncated control event rates (40%-80%) and for large trials. With these data, the relative risks for Postoperative Vomiting (five reports), nausea (five reports), nausea and Vomiting (eight reports), and rescue treatment (three reports) were 0.69 (95% CI, 0.58-0.82), 0.69 (95% CI, 0.54-0.87), 0.76 (95% CI, 0.66-0.88), and 0.68 (95% CI, 0.54-0.85), respectively. This means that of 100 patients who receive transdermal scopolamine, approximately 17 will not experience Postoperative Vomiting who would have done so had they all received a placebo. However, 18 of 100 patients will have visual disturbances, eight will report dry mouth, two will report dizziness, one will be classified as being agitated, and 1-13 patients who are prescribed transdermal scopolamine will not use it correctly. The timing of application does not alter efficacy. IMPLICATIONS Of 100 patients who receive transdermal scopolamine, approximately 17 will not vomit in the Postoperative period who would have done so had they all received a placebo. However, 18 of 100 patients will have visual disturbances, and eight will report dry mouth. Incorrect use further limits its efficacy.
Youngtae Jeon - One of the best experts on this subject based on the ideXlab platform.
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dexmedetomidine injection during strabismus surgery reduces emergence agitation without increasing the oculocardiac reflex in children a randomized controlled trial
PLOS ONE, 2016Co-Authors: In Ae Song, Jungwon Hwang, Kwangsuk Seo, Jiseok Baik, Jinhee Kim, Youngtae JeonAbstract:Objective Dexmedetomidine is known to reduce the incidence of emergence agitation, which is a common complication after inhalational anesthesia like sevoflurane or desflurane in children. However, the dose of dexmedetomidine used for this purpose is reported variously and the most effective dose is not known. In this study, we tried to find the most effective dose of dexmedetomidine to reduce the incidence of emergence agitation in children undergoing strabismus surgery without the complications like oculocardiac reflex (OCR) or Postoperative Vomiting. Methods We randomized 103 pediatric patients aged 2–6 years and undergoing elective strabismus surgery into four groups. Anesthesia was induced with sevoflurane and maintained with desflurane. At the start of induction, dexmedetomidine, delivered at 0.25, 0.5, or 1 μg/kg, or saline was infused intravenously in the D0.25, D0.5, D1 groups, respectively. The primary outcome measure was the incidence of emergence agitation and the secondary outcome measure was the incidence of intraoperative OCR, Postoperative Vomiting, and desaturation events. Results The incidence of emergence agitation was 60, 48, 44, and 21% (P = 0.005) and the incidence of intraoperative OCR was 36, 36, 36, and 37% (P = 0.988) in the control, D0.25, D0.5, and D1 groups, respectively. And, Postoperative Vomiting rate and desaturation events were low in the all groups. Conclusion Dexmedetomidine decreased the incidence of emergence agitation without increasing intraoperative oculocardiac reflex. Dexmedetomidine delivered at 1 μg/kg was more effective at reducing emergence agitation than lower doses in children undergoing strabismus surgery under desflurane anesthesia. Trial Registration Clinical Research Information Service KCT0000141
Peter Kranke - One of the best experts on this subject based on the ideXlab platform.
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the development and validation of a risk score to predict the probability of Postoperative Vomiting in pediatric patients
Anesthesia & Analgesia, 2004Co-Authors: L H J Eberhart, Peter Kranke, A M Morin, G Geldner, A Schauffelen, H Treiber, H WulfAbstract:Risk scores to predict the occurrence of Postoperative Vomiting (PV) or nausea and Vomiting that were developed for adult patients do not fit for children, because several risk factors are difficult to assess or are usually not applicable in pediatric patients (e.g., smoking status). Thus, in the present study, we sought to develop and to validate a simple score to predict PV in children (POVOC-score). Development and validation of the new score was based on data from 4 independent institutions of 1257 children (aged 0-14 yr) undergoing various types of surgery under general anesthesia without antiemetic prophylaxis. Preoperatively, several potential risk factors were recorded. Postoperatively, the occurrence of PV was observed for up to 24 h. The dataset was randomly split into an evaluation set (n = 657) that was analyzed using a forward logistic regression technique and a validation set (n = 600) that was used to confirm the accuracy of prediction by means of the area under a receiver operating characteristic curve. Four independent risk factors for PV were identified in the final analysis: duration of surgery >/=30 min, age >/=3 yr, strabismus surgery, and a positive history of PV in the children or PV/Postoperative nausea and Vomiting in relatives (mother, father, or siblings). The incidence of PV was 9%, 10%, 30%, 55%, and 70% for 0, 1, 2, 3, and 4 risk factors observed. Using these incidences as cut-off values in the validation dataset, the area under the receiver operating characteristic curve was 0.72 (95% confidence interval: 0.68-0.77). Our data suggest that PV can be predicted with an acceptable accuracy using a four-item simplified risk score.
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the efficacy and safety of transdermal scopolamine for the prevention of Postoperative nausea and Vomiting a quantitative systematic review
Anesthesia & Analgesia, 2002Co-Authors: Peter Kranke, A M Morin, Norbert Roewer, H Wulf, L H J EberhartAbstract:UNLABELLED The role of scopolamine administered via transdermal therapeutic systems in the prevention of Postoperative Vomiting, nausea, and nausea and Vomiting is unclear. We performed a systematic search for full reports of randomized comparisons of transdermal scopolamine with inactive control. Dichotomous data were extracted. In the meta-analysis, relative risks and numbers-needed-to-treat/harm were calculated with 95% confidence intervals (CI). In 23 trials, 979 patients received transdermal scopolamine, and 984 patients received placebo. Sensitivity analyses were performed using restricted data for truncated control event rates (40%-80%) and for large trials. With these data, the relative risks for Postoperative Vomiting (five reports), nausea (five reports), nausea and Vomiting (eight reports), and rescue treatment (three reports) were 0.69 (95% CI, 0.58-0.82), 0.69 (95% CI, 0.54-0.87), 0.76 (95% CI, 0.66-0.88), and 0.68 (95% CI, 0.54-0.85), respectively. This means that of 100 patients who receive transdermal scopolamine, approximately 17 will not experience Postoperative Vomiting who would have done so had they all received a placebo. However, 18 of 100 patients will have visual disturbances, eight will report dry mouth, two will report dizziness, one will be classified as being agitated, and 1-13 patients who are prescribed transdermal scopolamine will not use it correctly. The timing of application does not alter efficacy. IMPLICATIONS Of 100 patients who receive transdermal scopolamine, approximately 17 will not vomit in the Postoperative period who would have done so had they all received a placebo. However, 18 of 100 patients will have visual disturbances, and eight will report dry mouth. Incorrect use further limits its efficacy.
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volatile anaesthetics may be the main cause of early but not delayed Postoperative Vomiting a randomized controlled trial of factorial design
BJA: British Journal of Anaesthesia, 2002Co-Authors: Christian C Apfel, Peter Kranke, M H Katz, C Goepfert, T Papenfuss, Scott L Rauch, R Heineck, C A Greim, Norbert RoewerAbstract:Background Despite intensive research, the main causes of Postoperative nausea and Vomiting (PONV) remain unclear. We sought to quantify the relative importance of operative, anaesthetic and patient-specific risk factors to the development of PONV. Methods We conducted a randomized controlled trial of 1180 children and adults at high risk for PONV scheduled for elective surgery. Using a five-way factorial design, we randomly assigned subjects by gender who were undergoing specific operative procedures, to receive various combinations of anaesthetics, opioids, and prophylactic antiemetics. Results Of the 1180 patients, 355 (30.1% 95% CI (27.5–32.7%)) had at least one episode of Postoperative Vomiting (PV) within 24 h post-anaesthesia. In the early Postoperative period (0–2 h), the leading risk factor for Vomiting was the use of volatile anaesthetics, with similar odds ratios (OR (95% CI)) being found for isoflurane (19.8 (7.7–51.2)), enflurane (16.1 (6.2–41.8)) and sevoflurane (14.5 (5.6–37.4)). A dose–response relationship was present for the use of volatile anaesthetics. In contrast, no dose response existed for propofol anaesthesia. In the delayed Postoperative period (2–24 h), the main predictors were being a child (5.7 (3.0–10.9)), PONV in the early period (3.4 (2.4–4.7)) and the use of Postoperative opioids (2.5 (1.7–3.7)). The influence of the antiemetics was considerably smaller and did not interact with anaesthetic or surgical variables. Conclusion Volatile anaesthetics were the leading cause of early Postoperative Vomiting. The pro-emetic effect was larger than other risk factors. In patients at high risk for PONV, it would therefore make better sense to avoid inhalational anaesthesia rather than simply to add an antiemetic, which may still be needed to prevent or treat delayed Vomiting.