Safest and cheapest antiemetics should be used first for postoperative nauseaBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7453.1396 (Published 10 June 2004) Cite this as: BMJ 2004;328:1396
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About 75 million surgical patients worldwide are anaesthetised each
year, and without treatment a third will have postoperative nausea,
vomiting, or both1. The high incidence of postoperative nausea and
vomiting is in part due to the earlier mobilization and the growth in
ambulatory surgery 2.
Vomiting increases the risk of aspiration and has been associated with
esophageal rupture, pneumothoraxes, subcutaneous emphysema, and suture
dehiscence3, which may jeopardise the surgical success.
In a randomised controlled trial, with 5199 surgical patients submitted to
general anaesthesia, Apfel and colleagues3 assessed the relative efficacy
of three antiemetics: droperidol (1,25 mg), dexamethasone (4 mg), and
ondansetron (4 mg). The authors concluded that these antiemetics were
similarly effective, and so the safest or least expensive should be used
first. The low cost and excellent safety profile of both droperidol4 and
dexamethasone5 make the combination of these two drugs a highly cost-
effective strategy for preventing postoperative nausea and vomiting6, 3.
Nevertheless, it may prolong the QT interval7 and US FDA has recently
warned that droperidol may be associated with torsades de pointes2.
It would be useful to remember metoclopramide, an old and low-priced
antiemetic, that like droperidol blocks central (CTZ) dopaminergic (D2)
receptors, but has not yet been associated with torsades de pointes.
Furthermore, it has 2 great advantages, especially on ambulatory surgery:
1- it is less sedating than other central dopamine antagonists, and 2-
enhances GI motility8, which may be very important to reduce the danger of
gastric content aspiration on anaesthesia induction, a problem sometimes
aggravated by the stress induced gastroparesis.
1 - Safest and cheapest antiemetics should be used first for
postoperative nausea Scott Gottlieb. BMJ 2004;328:1396.
2 - White, Paul F. Prevention of Postoperative Nausea and Vomiting -
A Multimodal Solution to a Persistent Problem. N Engl J Med 2004;350: 2511
3 - Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six
interventions for the prevention of postoperative nausea and vomiting. N
Engl J Med 2004;350:2441-2451.
4 - White PF. Droperidol: a cost-effective antiemetic for over thirty
years. Anesth Analg 2002;95:789-90.
5 - Henzi I, Walder B, Tramer MR. Dexamethasone for the prevention of
postoperative nausea and vomiting: a quantitative systematic review.
Anesth Analg 1999;90:186-94.
6 - White PF, Watcha MF. Postoperative nausea and vomiting:
prophylaxis versus treatment. Anesth Analg 1999;89:1337-9.
7 - Dan M. Roden. Drug-Induced Prolongation of the QT Interval. N
Engl J Med 2004;350:1013-22.
8 - Harrison’s Online. http://harrisons.accessmedicine.com/ 2004
Competing interests: No competing interests