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Management of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy.Surgical Endoscopy Mar 2011The common and distressing complications of postoperative nausea and vomiting (PONV) are the main concern of 40-70% of patients undergoing laparoscopic cholecystectomy...
The common and distressing complications of postoperative nausea and vomiting (PONV) are the main concern of 40-70% of patients undergoing laparoscopic cholecystectomy (LC). The first step in preventing PONV after LC is to reduce the risk factors involving patient characteristics, surgical procedure, anesthetic technique, and postoperative care. Particularly, the use of propofol-based anesthesia can reduce the incidence of PONV after LC. Second, prophylactic antiemetics including antihistamines (dimenhydrinate), phenothiazines (perphenazine), butyrophenones (droperidol), benzamides (metoclopramide), dexamethasone, and serotonin receptor antagonists (ondansetron, granisetron, tropisetron, dolasetron, and ramosetron) are available for preventing PONV after LC. Third, antiemetic therapy combined with a serotonin receptor antagonist (ondansetron, granisetron) and droperidol or dexamethasone is highly effective in the prevention of PONV after LC. Fourth, acupressure at the P6 point is a nonpharmacologic technique that is as effective as ondansetron for preventing PONV after LC. Knowledge regarding the risk factors for PONV and antiemetics is needed for the management of PONV after LC.
Topics: Acupressure; Anesthesia, General; Anesthetics; Antiemetics; Cholecystectomy, Laparoscopic; Dexamethasone; Drug Therapy, Combination; Histamine Antagonists; Humans; Narcotics; Pneumoperitoneum, Artificial; Postoperative Nausea and Vomiting; Propofol; Risk Factors; Serotonin Antagonists
PubMed: 20927550
DOI: 10.1007/s00464-010-1193-9 -
American Journal of Therapeutics 2010Nausea and vomiting are 2 of the most upsetting adverse reactions of chemotherapy. Current guidelines propose 5-hydroxytryptamine3 (5-HT3) receptor antagonists as a... (Review)
Review
Nausea and vomiting are 2 of the most upsetting adverse reactions of chemotherapy. Current guidelines propose 5-hydroxytryptamine3 (5-HT3) receptor antagonists as a pharmacologic intervention for acute and delayed nausea and vomiting [chemotherapy-induced nausea and vomiting (CINV)] associated with moderately and highly emetogenic chemotherapy. Meanwhile, both postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting are challenging situations after surgeries and procedures. Prophylactic and therapeutic combinations of antiemetics are recommended in patients at high risk of suffering from PONV and postdischarge nausea and vomiting. Granisetron (Kytril) is a selective 5-HT3 receptor antagonist that does not induce or inhibit the hepatic cytochrome P-450 system in vitro. There are also 4 other antagonists of 5-HT3 receptor (dolasetron, ondansetron, palonosetron, and tropisetron) being metabolized via the CYP2D6 and are subject to potential genetic polymorphism. The launch of a new class of antiemetics, the substance P/neurokinin1 receptor antagonists, was attributed to the scientific update on the central generator responsible for emesis and role of substance P. There has been mounting interest in exploring integrative medicine, either acupuncture or acustimulation of P6 (Nei-Kuwan), to complement the western medicine for prevention and management of nausea and vomiting. The potential application of cannabinoids, either alone or in combination with other agents of different mechanism, could contribute further to improve outcome in CINV. Implementation of future treatment guidelines for more effective management of CINV and PONV could certainly improve the efficacy and outcome of cancer and postoperative care.
Topics: Antiemetics; Antineoplastic Agents; Dexamethasone; Female; Granisetron; Humans; Male; Nausea; Neoplasms; Postoperative Nausea and Vomiting; Serotonin 5-HT3 Receptor Antagonists; Vomiting
PubMed: 20844345
DOI: 10.1097/MJT.0b013e3181ea7821 -
Current Cardiology Reviews Aug 2009Severe and occasionally fatal arrhythmias, commonly presenting as Torsade de Pointes [TdP] have been reported with Class III-antiarrhythmics, but also with...
Severe and occasionally fatal arrhythmias, commonly presenting as Torsade de Pointes [TdP] have been reported with Class III-antiarrhythmics, but also with non-antiarrhythmic drugs. Most cases result from an action on K(+) channels encoded by the HERG gene responsible for the IKr repolarizing current, leading to a long QT and repolarization abnormalities. The hydrophobic central cavity of the HERG-K+ channels, allows a large number of structurally unrelated drugs to bind and cause direct channel inhibition. Some examples are dofetilide, quinidine, sotalol, erythromycin, grepafloxacin, cisapride, dolasetron, thioridazine, haloperidol, droperidol and pimozide. Other drugs achieve channel inhibition indirectly by impairing channel traffic from the endoplasmic reticulum to the cell membrane, decreasing channel membrane density (pentamidine, geldalamicin, arsenic trioxide, digoxin, and probucol). Whereas, ketoconazole, fluoxetine and norfluoxetine induce both direct channel inhibition and impaired channel trafficking. Congenital long QT syndrome, subclinical ion-channel mutations, subjects and relatives of subjects with previous history of drug-induced long QT or TdP, dual drug effects on cardiac repolarization [long QT plus increased QT dispersion], increased transmural dispersion of repolarization and T wave abnormalities, use of high doses, metabolism inhibitors and/or combinations of QT prolonging drugs, hypokalemia, structural cardiac disease, sympathomimetics, bradycardia, women and older age, have been shown to increase the risk for developing drug-induced TdP. Because most of these reactions are preventable, careful evaluation of risk factors and increased knowledge of drugs use associated with repolarization abnormalities is strongly recommended. Future genetic testing and development of practical and simple provocation tests are in route to prevent iatrogenic TdP.
PubMed: 20676275
DOI: 10.2174/157340309788970397 -
Brain Research Sep 2010The balance between descending inhibition and facilitation is thought to be disturbed in chronic pain states. Increased facilitation by spinally released serotonin has...
The balance between descending inhibition and facilitation is thought to be disturbed in chronic pain states. Increased facilitation by spinally released serotonin has been suggested by demonstration that mechanically evoked neuronal responses of wide dynamic range neurons are inhibited by 5-HT3 receptor antagonists in rats following spinal nerve ligation (SNL) but not sham operation. Despite these physiologic data, the effects of spinal 5-HT3 receptor blockade on behavioral hypersensitivity and neurochemical alterations in spinal serotonergic system have not been thoroughly investigated following spinal nerve ligation in the rat. To test this, we acutely injected intrathecal ondansetron in rats between 14 and 30 days after SNL and assessed effects on thermal and mechanical hypersensitivity. We also determined the density of serotonergic nerve fibers, serotonin content and the levels of 5-HT3 receptors within the spinal cord at this time point. Intrathecal ondansetron (1, 3, 10, 30, and 100microg) produced no effect on behavioral measures of thermal or mechanical hypersensitivity whereas intrathecal morphine (1microg) and gabapentin (200microg) partially reversed thermal and mechanical hypersensitivity following SNL. In addition, SNL did not alter the density of serotonergic fibers or 5-HT3 receptor immunoreactivity or spinal tissue content of 5-HT within the dorsal horn. These results do not support anatomic plasticity of descending serotonergic pathways or tonic 5-HT3 receptor activity in maintaining hypersensitivity after nerve injury and in contrast to previous studies fail to demonstrate an anti-hypersensitivity effect of intrathecal injection of the 5-HT3 receptor antagonist ondansetron. Importantly, behavioral measures of mechanical hypersensitivity assess threshold responses whereas physiological studies of mechanically evoked neuronal responses involve application of suprathreshold stimuli. Thus, suprathreshold or more intense stimuli may be necessary to recruit descending serotonergic facilitatory drive required to observe the inhibitory effects of ondansetron on spinal neuronal excitability and behavioral hypersensitivity.
Topics: Amines; Analgesics; Animals; Cyclohexanecarboxylic Acids; Excitatory Amino Acid Antagonists; Gabapentin; Indoles; Injections, Spinal; Ligation; Ondansetron; Pain; Quinolizines; Rats; Receptors, Serotonin, 5-HT3; Serotonin Antagonists; Spinal Nerves; gamma-Aminobutyric Acid
PubMed: 20637741
DOI: 10.1016/j.brainres.2010.07.020 -
Supportive Care in Cancer : Official... Jun 2011The objective of this work is to perform a systematic review and meta-analysis of all randomized controlled trials comparing a single intravenous dose of palonosetron... (Comparative Study)
Comparative Study Meta-Analysis Review
Efficacy of palonosetron (PAL) compared to other serotonin inhibitors (5-HT3R) in preventing chemotherapy-induced nausea and vomiting (CINV) in patients receiving moderately or highly emetogenic (MoHE) treatment: systematic review and meta-analysis.
OBJECTIVE
The objective of this work is to perform a systematic review and meta-analysis of all randomized controlled trials comparing a single intravenous dose of palonosetron (PAL) 0.25 mg with other 5-HT(3)R in patients receiving moderately or highly emetogenic (MoHE) chemotherapy.
METHODS
Several databases were searched, including MEDLINE, EMBASE, LILACS, and CENTRAL. The primary endpoints were the incidence of acute and delayed nausea and vomiting. The side effects of each treatment were analyzed. A subgroup analysis was performed to evaluate the influence of the use of corticosteroids. The results are expressed as risk ratio (RR) and the correspondent 95% confidence interval (CI).
RESULTS
Five studies were included, with 2057 patients. PAL was compared with ondansetron, granisetron, and dolasetron. Patients in PAL group had less nausea, both acute (RR = 0.86; CI 95% = 0.76 to 0.96; p = 0.007) and delayed (RR = 0.82; CI95% = 0.75 to 0.89; p < 0.00001). They also had less acute vomiting (RR = 0.76; CI 95% = 0.66 to 0.88; p = 0.0002) and delayed vomiting (RR = 0.76; CI95% = 0.68 to 0.85; p < 0.00001). There were no statistical differences in side effects like headache (RR = 0.84; CI 95% = 0.61 to 1.17; p = 0.30), dizziness (RR = 0.40; CI 95% = 0.13 to 1.27; p = 0.12), constipation (RR = 1.29; CI 95% = 0.77 to 2.17; p = 0.33) or diarrhea (RR = 0.67; CI 95% = 0.24 to 1.85; p = 0.44). Patients receiving PAL presented less nausea and vomiting regardless of the use of corticoids. We found no statistical heterogeneity in the global analysis.
CONCLUSION
PAL was more effective than the other 5-HT(3)R in preventing acute and delayed CINV in patients receiving MoHE treatments, regardless of the use of concomitant corticosteroids.
Topics: Antiemetics; Antineoplastic Agents; Glucocorticoids; Humans; Isoquinolines; Nausea; Neoplasms; Palonosetron; Quinuclidines; Serotonin 5-HT3 Receptor Antagonists; Vomiting
PubMed: 20495832
DOI: 10.1007/s00520-010-0908-8 -
Journal of Spinal Disorders & Techniques Apr 2010A preintervention and postintervention design was used to examine a total of 200 patients. (Comparative Study)
Comparative Study
STUDY DESIGN
A preintervention and postintervention design was used to examine a total of 200 patients.
OBJECTIVE
After successful implementation at our institution of a perioperative oral multimodal analgesia protocol in major joint arthroplasty, a modified regimen was provided to patients undergoing spine procedures.
SUMMARY OF BACKGROUND DATA
A proactive, multimodal approach is currently recommended for the management of acute postoperative pain. Inadequate postoperative analgesia can negatively influence surgical outcome and duration of rehabilitation. Routine use of intravenous patient controlled analgesia (IV PCA) after surgery can result in substantial functional interference, side effects, and lead to untoward events as a result of programming errors.
METHODS
A preintervention and postintervention design was used to compare a historical control group of spine surgery patients who received conventional IV PCA (N=100) with a prospective group who received some form of perioperative oral multimodal analgesia (N=100). The new regimen included preoperative and postoperative scheduled extended-release oxycodone, gabapentin, and acetaminophen, intraoperative dolasetron and as-needed postoperative short-acting oral oxycodone. Patient surveys and chart audits were used to measure pain intensity, functional interference from pain, opioid consumption, analgesic-related side effects, and patient satisfaction over the first 24 hours postoperatively.
RESULTS
Patients who received the new perioperative multimodal oral regimen had significantly less opioid consumption (P<0.001), lower ratings of Least Pain (P<0.01), and experienced less nausea (P<.001), drowsiness (P<0.05), interference with walking (P=0.05), and coughing and deep breathing (P<0.05) compared with the IV PCA group.
CONCLUSIONS
This quality improvement study shows some safety and significant advantages of a multimodal perioperative oral analgesic regimen compared with standard IV PCA after spine surgery.
Topics: Acetaminophen; Administration, Oral; Amines; Analgesia; Analgesia, Patient-Controlled; Analgesics; Arthroplasty; Combined Modality Therapy; Cyclohexanecarboxylic Acids; Female; Gabapentin; Humans; Indoles; Injections, Intravenous; Male; Oxycodone; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Preoperative Care; Prospective Studies; Quinolizines; Spine; Treatment Outcome; gamma-Aminobutyric Acid
PubMed: 20375829
DOI: 10.1097/BSD.0b013e3181cf07ee -
Current Drug Safety Jan 2010Several drugs acting on the nervous system have been implicated in the prolongation of the QT interval. Leaving aside the antidepressant and antipsychotic drugs, some... (Review)
Review
Several drugs acting on the nervous system have been implicated in the prolongation of the QT interval. Leaving aside the antidepressant and antipsychotic drugs, some have shown to prolong the QT interval in vivo. These include opioids, particularly methadone, inhalational anesthetics, and some preparations used for treatment of cough. These drugs have a narrow therapeutic interval or possible drug interactions that lead to clinical toxicity manifested by arrhythmias. They share the ability to block potassium channels (HERG), prolong the action potential and QT interval, and generate arrhythmias and Torsades de Pointes like other typicality recognized like antiarrhythmics, antihistamines, prokinetics, psychotropics and anti-infectives agents. Muscle relaxants like alcuronium, pancuronium and atracurium associated with or without atropine prolong significantly the QT interval. Methadone is the opiod most tightly associated with QTc prolongation; with much lesser potency buprenorphine and oxycodone can block HERG channels and depress the IKr current in vitro.Antineoplastic chemotherapy like anthracyclines, alkylating drugs, alkilants and cisplatin are associated with electrocardiographic alterations including prolongation of QT and emesis of different grades. It's very important take in account the synergic effects over the QT prolongation when effective antiemetics like 5-HT3 receptor antagonist (granisetron, ondansetron, and dolasetron) are administered. The Knowledge of their pharmacological properties is of vital importance to avoid exposing particularly vulnerable individuals as those with congenital long QT syndrome, and even the general public to unnecessary risk of potentially fatal arrhythmias.
Topics: Analgesics, Opioid; Anesthetics, Inhalation; Animals; Antitussive Agents; Central Nervous System Agents; Drug Interactions; ERG1 Potassium Channel; Ether-A-Go-Go Potassium Channels; Humans; Long QT Syndrome; Risk Factors; Torsades de Pointes
PubMed: 20210727
DOI: 10.2174/157488610789869256 -
Journal of Feline Medicine and Surgery Mar 2010The control of nausea and vomiting in cats is important in order to prevent the development of food aversion, anorexia (with its associated complications of weight loss... (Review)
Review
PRACTICAL RELEVANCE
The control of nausea and vomiting in cats is important in order to prevent the development of food aversion, anorexia (with its associated complications of weight loss and dehydration), and hepatic lipidosis.
CLINICAL CHALLENGES
There are several antiemetic drugs that are clinically effective in cats. Making a rational choice from the available options requires knowledge of the likely cause of the vomiting, and the mechanisms of action and side effects of each drug. For example, a drug such as prochlorperazine, which can cause sedation, may be a useful first-line choice in a hospitalized cat that requires mild sedation to be handled, but would be undesirable in a critically ill cat.
AUDIENCE
For companion animal and feline practitioners, the vomiting cat is a common presentation.
EVIDENCE BASE
The guidance provided in this review draws on the findings of clinical trials in humans, experimental studies in cats, some clinical trials in cats, and clinical experience.
Topics: Acute Disease; Animals; Antiemetics; Cat Diseases; Cats; Chlorpromazine; Diarrhea; Famotidine; Indoles; Metoclopramide; Nausea; Ondansetron; Prochlorperazine; Quinolizines; Quinuclidines; Ranitidine; Sucralfate; Vomiting; Weight Loss
PubMed: 20193913
DOI: 10.1016/j.jfms.2010.01.005 -
Expert Review of Anticancer Therapy Feb 2010A large number of different 5-hydroxytryptamine (HT)(3) receptor antagonists have been marketed with the indication of preventing nausea and vomiting induced by... (Review)
Review
A large number of different 5-hydroxytryptamine (HT)(3) receptor antagonists have been marketed with the indication of preventing nausea and vomiting induced by chemotherapy--palonosetron is the most recently developed of these. Pharmacologic studies have revealed that palonosetron has a long half-life, a high affinity for 5-HT(3) receptors, exhibits allosteric binding to 5-HT(3) receptors and possess positive cooperativity. Although interesting, pharmacologic differences are only useful if they result in clinical advantages, such as an increase in efficacy and/or an improvement in tolerability. We summarize preclinical and clinical studies of palonosetron and compare the efficacy and tolerability with the other 5-HT(3) receptor antagonists, ondansetron, granisetron and dolasetron.
Topics: Antiemetics; Antineoplastic Agents; Clinical Trials as Topic; Humans; Isoquinolines; Nausea; Palonosetron; Quinuclidines; Vomiting
PubMed: 20131990
DOI: 10.1586/era.09.175 -
Paediatric Drugs 2010Existing guidelines for the prevention of antineoplastic chemotherapy-induced nausea and vomiting (CINV) in children are constrained by the lack of robust evidence.... (Review)
Review
Existing guidelines for the prevention of antineoplastic chemotherapy-induced nausea and vomiting (CINV) in children are constrained by the lack of robust evidence. Current guidelines recommend the use of a serotonin 5-HT(3) receptor antagonist plus a corticosteroid to prevent acute CINV. Consequently, antiemetic agents that are recommended for use in adult cancer patients do not appear in the current pediatric guidelines. In addition, there is no information to guide the selection of alternative antiemetic agents for children who either cannot receive the recommended agents or who do not respond adequately to the treatment. Possible barriers to adherence to the pediatric antiemetic selection guidelines that are currently available are discussed, and published pediatric experience with antiemetic agents recommended in the current adult antiemetic selection guidelines (dolasetron, tropisetron, palonosetron, aprepitant) is summarized in this review. The use of novel and emerging antiemetic therapeutic interventions {metopimazine, diphenhydramine (Benadryl)-lorazepam (Avitan)-dexamethasone (Decadron) [BAD], nabilone, acupuncture, midazolam, olanzapine, mirtazapine, gabapentin, droperidol} in children are explored.
Topics: Acupuncture; Antiemetics; Antineoplastic Agents; Cannabinoids; Drug Combinations; Electrocardiography; Glucocorticoids; Guideline Adherence; Headache; Humans; Nausea; Neurokinin-1 Receptor Antagonists; Pediatrics; Practice Guidelines as Topic; Serotonin Antagonists; Vomiting
PubMed: 20034341
DOI: 10.2165/11316190-000000000-00000