The impact of preinduction fentanyl dosing strategy on postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy

Amitabh Dutta, MD; Nitin Sethi, DNB; Prabhat Choudhary, MD; Jayashree Sood, MD; Bhuwan Chand Panday, MD; Parul Takkar Chugh, MSc

doi:10.5055/jom.2018.0460

Authors

Amitabh Dutta, MD
Nitin Sethi, DNB
Prabhat Choudhary, MD
Jayashree Sood, MD
Bhuwan Chand Panday, MD
Parul Takkar Chugh, MSc

DOI:

https://doi.org/10.5055/jom.2018.0460

Keywords:

fentanyl, postoperative nausea, vomiting, laparoscopy

Abstract

Objective: Postoperative nausea and vomiting (PONV) is commonly attributed to opioid analgesics; consequently, perioperative opioid dosage reduction is a common practice. However, inadequate fentanyl analgesia may have adverse implications (sympathetic activation, pain). We conducted this randomized clinical study to analyze whether preinduction fentanyl 3 μg kg−1 administered by different techniques increases incidence of PONV.

Design: Randomized-control, prospective, investigator and observer blinded, two-arm, single-center comparison.

Setting: Operating room, postoperative ward.

Patients: Two hundred seventy patients, aged 20-60 years of either sex and belonging to ASA physical status I/II, scheduled to undergo laparoscopic cholecystectomy under general anesthesia.

Interventions: The patients were randomly allocated to receive preinduction fentanyl 3 μg kg−1 administered by “single-bolus,” three equally divided “intermittent boluses” or a “short-infusion” technique.

Main outcome measures: The patients were evaluated for PONV profile (primary outcome); and postoperative parameters (pain, sedation, respiratory depression) (secondary outcome).

Results: Two hundred fifty-seven patients completed the study and 29.1 percent (n = 75) experienced PONV. The study groups were comparable for PONV incidence (“single-bolus”: n = 23, 25.8 percent; “intermittent-boluses”: n = 27, 32.5 percent; “short-infusion”: n = 25, 29.4 percent), total frequency of PONV (“single-bolus”: n = 28, 31.5 percent; “intermittent-boluses”: n = 39, 47.0 percent; “short-infusion”: n = 36, 42.4 percent), and frequency of rescue antiemetic usage (“single-bolus”: n = 24, 30.7 percent; “intermittent-boluses”: n = 28, 35.8 percent; “short-infusion”: n = 26, 33.3 percent). Patients who received preinduction fentanyl as “intermittent-boluses” were less sedated in the postoperative period (p < 0.001).

Conclusions: Controlled administration of preinduction fentanyl 3 μg kg−1 by commonly employed administration methods does not seem to impact PONV profile. Further studies are needed to establish a temporal link between preinduction fentanyl and PONV.

Author Biographies

Amitabh Dutta, MD

Senior Consultant & Professor, Department of Anaesthesiology, Pain, and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India

Nitin Sethi, DNB

Consultant & Associate Professor, Department of Anaesthesiology, Pain, and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India

Prabhat Choudhary, MD

Consultant, Department of Anaesthesiology, Pain, and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India

Jayashree Sood, MD

Senior Consultant, Professor & Chairperson, Department of Anaesthesiology, Pain, and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India

Bhuwan Chand Panday, MD

Consultant & Associate Professor, Department of Anaesthesiology, Pain, and Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi, India

Parul Takkar Chugh, MSc

Biostatistician, Department of Research, Sir Ganga Ram Hospital, New Delhi, India.

References

Smith HS, Smith EJ, Smith BR: Postoperative nausea and vomiting. Ann Palliative Med. 2012; 1: 94-102.

Hirsch J: Impact of postoperative nausea and vomiting in the surgical setting. Anaesthesia. 1994; 49: 30-31.

So JB, Cheong KF, Sng C, et al.: Ondansetron in the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: A prospective randomized study. Surg Endosc. 2002; 16: 286-288.

Hall MJ, Owings ME: National hospital discharge survey. Advance data from vital and health statistics. No 329: Hyattsville, Md: Natl Centre Health Stat, 2002: DHHHS publication no. (PHS) 2002-125002-0428.

Marcario A, Weinger M, Carney S, et al.: Which clinical anesthesia outcomes are important to avoid?. The perspective of patients. Anesth Analg. 1999; 89: 652-658.

Herndon CM, Jackson KC 2nd, Hallin PA: Management of opioid-induced gastrointestinal effects in patients receiving palliative care. Pharmacotherapy. 2002; 22: 240-250.

Watcha MF, White PF: Postoperative nausea and vomiting. Its etiology, treatment and prevention. Anesthesiology. 1992; 77: 162-184.

Smith I, Walley G, Bridgman S: Omitting fentanyl reduces nausea and vomiting, without increasing pain, after sevoflurane for day surgery. Eur J Anaesthesiol. 2008; 25: 790-799.

Bailey PL, Egan TG, Stanley TH: Intravenous opioid anesthetics. In Miller RD (editor): Anesthesia. New York: Churchill Livingstone; 2000, pp. 273-376.

Apfel CC, Laara E, Koivuranta M, et al.: A simplified risk score for predicting postoperative nausea and vomiting: Conclusions from cross-validations between two centres. Anesthesiology. 1999; 91: 693-700.

Flacke JW, Bloor BC, Kripke BJ, et al.: Comparison of morphine, meperidine, fentanyl, and sufentanil in balanced anesthesia: A double-blind study. Anesth Analg. 1985; 64: 897-910.

Kokinsky E, Nilsson K, Larsson LE: Increased incidence of postoperative nausea and vomiting without additional analgesic effects when a low dose of intravenous fentanyl is combined with a caudal block. Paediatr Anaesth. 2003; 13: 334-338.

Stoelting RK: Opioid agonists and antagonists. In Stoelting RK (editor): Pharmacology and Physiol Anesthetic Pract. Philadelphia: Lippincott-Raven, 1999, pp. 93-94.

Shafer SL, Varvel JR: Pharmacokinetics, pharmacodynamics, and rational opioid selection. Anesthesiology. 1991; 74: 53-63.

Coda BA: Opioid. In Barash PG, Cullen PG, Stoelting RK (eds): Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins, 2001, pp. 355-366.

Gecaj-Gashi A, Hashmi M, Sada F, et al.: Propofol vs isoflurane anesthesia-incidence of PONV in patients at maxillofacial surgery. Advances Med Sci. 2010; 55: 308-312.

Erhan Y, Erhan E, Aydede H, et al.: Ondansetron, granisetron, and dexamethasone compared for the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: A randomized placebo-controlled study. Surg Endosc. 2008; 22: 1487-1492.

Sandhu T, Tanvatcharaphan P, Cheunjongkolkul V: Ondansetron versus metaclopramide in prophylaxis of nausea and vomiting for laparoscopic cholecystectomy: A prospective double-blind randomized study. Asian J Surg. 2008; 31: 50-54.

Bianchin A, De Luca A, Caminiti A: Postoperative vomiting reduction after laparoscopic cholecystectomy with single dose of dexamethasone. Minerva Anesthesiol. 2007; 73: 343-346.

Nesek-Adam V, Grizelj-Stojcic´ E, Rasic´ Z, et al.: Comparison of dexamethasone, metoclopramide, and their combination in the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy. Surg Endosc. 2007; 21: 607-612.

Freye E, Latasch L: Development of opioid tolerance-molecular mechanisms and clinical consequences. Anaesthesiol Intensivmed NotfallmedSchmerzther. 2003; 38: 14-27.

Barnes NM, Bunce KT, Naylor RJ, et al.: The actions of fentanyl to inhibit drug-induced emesis. Neuropharmacology. 1991; 30: 1073-1083.

Venneman NG, Van Erpecum KJ: Pathogenesis of gallstones. Gastroenterol Clin North Am. 2010; 39: 171-183.

Lerman J: Surgical and patient factors involved in PONV. Br J Anaesth. 1992; 69: 24-32.

Jo YY, Lee JW, Shim JK, et al.: Ramosetron, dexamethasone, and their combination for the prevention of postoperative nausea and vomiting in women undergoing laparoscopic holecystectomy. Surg Endosc. 2012; 26: 2306-2311.

Alghanem SM, Massad IM, Rashed EM, et al.: Optimization of anesthesia antiemetic measures versus combination therapy using dexamethasone or ondansetron for the prevention of postoperative nausea and vomiting. Surg Endosc. 2010; 24: 353-358.

Murphy GS, Szokol JW, Greenberg SB, et al.: Preoperative dexamethasone enhances quantity of recovery after laparoscopic cholecystectomy: Effect on in-hospital and post discharge recovery outcomes. Anesthesiology. 2011; 114: 882-890.

Wu SJ, Xiong XZ, Lin YX, et al.: Comparison of the efficacy of ondansetron and granisetron to prevent postoperative nausea and vomiting after laparoscopic cholecystectomy: A systematic review of meta-analysis. Surg Laparosc Endosc Percut Tech. 2013; 23: 79-87.

Oliveira Jr. GSD, Castro-Alves LJS, Ahmad S, et al.: Dexamethasone to prevent postoperative nausea and vomiting: An updated meta-analysis of randomized controlled trials. Anesth Analg. 2013; 116: 58-74.