術(shù)后惡心嘔吐的預(yù)防和治療ppt課件

1、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 T/Historical Perspective o

2、n 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 size estimate and

3、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

4、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 analysisnAppropriatene

5、ss of endpoints chosennConfidence limits particularly for negative studiesnStatistical analysisCritical Evaluation of DatanQuality of individual clinical trialsnEvaluation of data in aggregateEvidence Based MedicineRating ScaleLevel of evidence based on study designI. Large randomized, controlled tr

6、ial (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 recommend

7、ationC. Insufficient evidence to recommend for or againstCritical Evaluation of DatanQuality of individual clinical trialsnEvaluation of data in aggregatenEstimation of treatment consequencesMeasures of Treatment ConsequencesRelative Risk ReductionThe reduction of adverse events achieved by a treatm

8、ent, expressed as a proportion of the control rateOdds RatioThe traditional expression of the relative likelihood of an outcome expressed as P/(1 - P) where P = probabilityAbsolute Risk ReductionThe difference in event rates between the control and treatment groupsNumbers Needed to be Treated (NNT)T

9、he 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;318:1728-1733Measures of Treatment ConsequencesNumbers Needed to be TreatedRelative Risk Reduction0.5 - 0.300.50

10、= 0.40Odds Ratio0.30 / (1 - 0.30)0.50 / (1 - 0.50) = 0.43Absolute Risk Reduction0.5 - 0.3 = 0.20 1 0.5 - 0.3 = 5 Placebo = 0.50Treatment = 0.30Rates of Adverse EventsLaupacis et al. NEJM 1988;318:1728-1733TopicsRisk factorsPharmacologic approaches to managementAdjuvants (nonpharmacologic)Efficacy ve

11、rsus outcomePrevention versus treatmentPostdischarge nausea and vomitingMultimodal managementTopicsnRisk factorsRisk FactorsnNon-anesthetic factorsnAnesthetic related factorsnPostoperative factorsRisk FactorsnAgenGendernBody habitusnHx motion sicknessnHx PONVnAnxietynConcomitant diseasenOperative pr

12、ocedurenDuration of surgeryNon-anesthetic FactorsRisk FactorsnPreanesthetic medicationnGastric distensionnGastric suctioningnAnesthetic techniquenAnesthetic agentsAnesthetic Related FactorsRisk FactorsnPainnDizzinessnAmbulationnOral intakenOpioidsPostoperative FactorsRisk FactorsPatient SpecificPala

13、zzo M, Evans R. Logistic regression analysis of fixed patient factors for postoperative sickness: a model for risk assessment. Br J Anaesth 1993;70:-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

14、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

15、 FactorsPatient SpecificnFemalenNonsmoking history nHx of motion sickness or PONVnUse of postoperative opioidsSimplified Scoring SystemIncidence of PONVRisk FactorsIncidence010%121%239%361%479%Apfel CC et al. Anesthesiology 1999;91:693-700.Risk FactorsAnesthetic RelatedRisk FactorsOR*CIVolatile anes

16、thetics 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 RelatedOmission of Nitrous Oxide during Anesthesia Reduces the Incidence of Postoperative Nausea and Vomiting. A Meta-An

17、alysisDivatia et al. Anesthesiology 1996;85:1055-1062Twenty-Four of Twenty-Seven Studies Show a Greater Incidence of Emesis Associated with Nitrous Oxide than with Alternative AnestheticsHartung. Anesth Analg 1996;83:114-116Omitting Nitrous Oxide in General Anaesthesia: Meta-Analysis of Intraoperati

18、ve Awareness and Postoperative Emesis in Randomized Controlled TrialsTramer et al. BJA 1996;76:186-193Nitrous 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 in

19、traoperative awarenessOmitting nitrous oxide from general anesthesia:Tramer et al. BJA 1996;76:186-193Nitrous Oxide and PONV Risk FactorsSurgical Risk FactorsDuration of Surgery Type of Surgery Apfel et al. BJA 2002;88:659-668Sinclair et al. Anesthesiology 1999; 91:109-118Sinclair et al. Anesthesiol

20、ogy 1999; 91:109-118Apfel et al. BJA 2002;88:659-668Fabling et al. Anesth Analg 2000;91:358-361Gan et al. Anesthesiology 1996;85:1036-1042Evidence Based MedicineRisk Factors for PONV in AdultsPatient-specific factorsFemale gender (I-A)Nonsmoking status (IV-A)History of PONV/motion sickness (IV-A)Ane

21、sthetic 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; 97:62-71TopicsRisk factorsPharmacologic approaches to management

22、Currently Available Medicationsn5HT3 (serotonin) antagonists - ondansetronnButyrophenones - droperidolnBenzamides - metoclopramidenAntihistamines - promethazine, dimenhydrinatenSteroids - dexamethasonenPhenothiazines- promethazine, prochlorperazinenAnticholinergics scopolamineEvidence Rating for Ant

23、iemeticsStrength 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

24、. 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:

25、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

26、-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

27、 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

28、 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:

29、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

30、 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

31、-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-APre

32、vention 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*PreventionTreatmentPreventionTreatmen

33、tOndansetron 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 dexam

34、ethasone 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 qu

35、antitative 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 EvidenceTrea

36、tment 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:Dimen

37、hydrinateEarly (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

38、 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 p

39、laceboNo 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

40、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?Metoclopramid

41、e-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, an

42、d 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*PreventionTreatmentPreventionTreatmentOnda

43、nsetron 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

44、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 Agitation

45、100.1Kranke, 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

46、-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 preve

47、ntion 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 postoperativ

48、e 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 vomiti

49、ng. 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.

50、 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

51、: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-41Preven

52、tion 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 ambula

53、tory 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;-Ondansetron III-ADexamethasone III-ADolasetron III-ABreakthrough PONV:Repeat Dosing Wi

54、th OndansetronKovac et al. J. Clin Anesth 1999;11:453-459* p = 0.074 p = 0.342I-ATopicsRisk factorsPharmacologic approaches to managementAdjuvants (nonpharmacologic)Management of PONV:Adjuvants (Nonpharmacologic)nP-6 acupuncture point stimulation III-AnSupplemental oxygen III-CnAggressive perioperat

55、ive rehydration III-AnPreemptive analgesia IV-ATopicsRisk factorsPharmacologic approaches to managementAdjuvants (nonpharmacologic)Efficacy versus outcomeEfficacy Versus OutcomeIf efficacy alone is an appropriate endpoint when evaluating analgesics, why isnt efficacy a valid endpoint when evaluating

56、 antiemetics?TopicsRisk factorsPharmacologic approaches to managementAdjuvants (nonpharmacologic)Efficacy versus outcomePrevention versus treatmentPrevention versus TreatmentFrequency of PACU Treatment by Risk Factors and Group RISK FACTORS PACU TREATMENTREQUIRED BY GROUPSubgroupGenderPriorHistoryEm

57、etogenicProcedure1OndansetronPlaceboAMaleYesYes0%50%BMaleYesNo25%38%CMaleNoYes7%25%DMaleNoNo16%16%EFemaleYesYes38%57%FFemaleYesNo45%53%GFemaleNoYes29%31%HFemaleNoNo14%17%1 Emetogenic procedures - laparoscopy, strabismus surgery, middle ear surgery, herniography,tonsillectomy, adenoidectomy, uvulopal

58、atopharyngoplastyScuderi 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 pati