Pediatric Anesthesia ISSN 1155-5645
ORIGINAL ARTICLE
Dexamethasone, ondansetron, and their combination and postoperative nausea and vomiting in children undergoing strabismus surgery: a meta-analysis of randomized controlled trials Yun-Dun Shen1, Chien-Yu Chen2,3, Chih-Hsiung Wu4,5, Yih-Giun Cherng6,7 & Ka-Wai Tam4,5,8,9,10 1 Department of Ophthalmology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan 2 Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan 3 Graduate Institute of Humanities in Medicine, Taipei Medical University, Taipei, Taiwan 4 Division of General Surgery, Department of Surgery, Taipei Medical, University-Shuang Ho Hospital, New Taipei City, Taiwan 5 Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan 6 Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan 7 Department of Anesthesiology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan 8 Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan 9 Center for Evidence-Based Medicine, Taipei Medical University, Taipei, Taiwan 10 Center for Evidence-Based Health Care, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
Keywords dexamethasone; meta-analysis; ondansetron; pediatric; postoperative nausea and vomiting; strabismus Correspondence Ka-Wai Tam and Yih-Giun Cherng, Center for Evidence-Based Health Care, Taipei Medical University-Shuang Ho Hospital, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City 23561, Taiwan Emails: [email protected]; [email protected] Section Editor: Jerrold Lerman Accepted 24 January 2014 doi:10.1111/pan.12374
490
Summary Background: Postoperative nausea and vomiting (PONV) is a common complication after pediatric strabismus surgery. Steroids and ondansetron (a 5-HT3 antagonist) can effectively reduce nausea, vomiting, and pain and thus might be useful agents for the prevention of PONV in pediatric patients. The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the prophylactic effects of dexamethasone and ondansetron on PONV after strabismus surgery in pediatric patients. Methods: A comprehensive literature search was conducted to identify RCTs that investigated the efficacy and safety of intravenous dexamethasone or ondansetron on PONV in pediatric strabismus surgical patients. The primary outcome was the incidence of PONV during the initial 24 postoperative hours. The secondary outcomes were number of patients requiring a rescue antiemetic and complications. Results: We included 13 RCTs that evaluated 2006 patients. In the two studies that compared dexamethasone and placebo treatments, POV occurred in 34.3% (23/67) of the patients in the dexamethasone group and in 68.2% (45/66) of the patients in the placebo group. The difference between the two groups was significant (RR 0.50; 95% confidence interval (CI) 0.34–0.72). Similarly, seven studies that compared ondansetron and a placebo identified a relatively lower incidence of PONV in the ondansetron group (103/277, 37.2%) than in the placebo group (177/270, 65.6%). The difference between the two groups was also significant (RR 0.58; 95% CI 0.43–0.79). The combination of dexamethasone and ondansetron was significantly more effective at reducing the incidence of POV than dexamethasone or ondansetron alone. In all included RCTs, experimental drug-related complications, such as facial flushing and headache, were limited.
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 490–498
Y.-D. Shen et al.
Effects of dexamethasone and ondansetron on PONV
Conclusions: Surgeons and anesthesiologists are recommended to administer the combination of dexamethasone and ondansetron to pediatric patients undergoing strabismus surgery.
Introduction Pediatric strabismus surgery is associated with frequent postoperative nausea and vomiting (PONV). The incidence of PONV after strabismus surgery ranges from 37% to 90% if no prophylactic antiemetic is provided to the patient (1). The major risk factors for PONV in pediatric surgery include the type of surgery (e.g., strabismus surgery and tonsillectomy), age >3 years, duration of anesthesia >30 min, motion sickness, and a personal or family history of PONV (2,3). The additional risk factors for PONV include the surgical techniques used and the number of muscles repaired 4. The proposed underlying mechanisms for frequent PONV after strabismus surgery include the oculoemetic reflex, which is a vagally mediated reflex related to eye muscle manipulation, and alterations in visual perception postoperatively (1,2). In addition to causing discomfort to patients, PONV increases the risk of adverse consequences and, left untreated, can result in complications such as dehydration, electrolyte imbalance, subconjunctival hemorrhage, the loosening of surgical attachments, delayed hospital discharge, and unplanned hospital admission (2). Several studies have showed that preoperative dexamethasone treatment reduces PONV after oral surgery, orthopedic surgery, thyroidectomy, and laparoscopic surgery (5,6). In a double-blind randomized controlled trial (RCT), the incidence and severity of PONV in the first 24 h were significantly lower in the patients treated with dexamethasone than in those administered a placebo (7). Ondansetron is a 5-HT3 antagonist that is commonly administered to pediatric strabismus surgical patients. In a study by Bowhay et al. (8), children treated with ondansetron were associated with
ORIGINAL ARTICLE
Dexamethasone, ondansetron, and their combination and postoperative nausea and vomiting in children undergoing strabismus surgery: a meta-analysis of randomized controlled trials Yun-Dun Shen1, Chien-Yu Chen2,3, Chih-Hsiung Wu4,5, Yih-Giun Cherng6,7 & Ka-Wai Tam4,5,8,9,10 1 Department of Ophthalmology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan 2 Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan 3 Graduate Institute of Humanities in Medicine, Taipei Medical University, Taipei, Taiwan 4 Division of General Surgery, Department of Surgery, Taipei Medical, University-Shuang Ho Hospital, New Taipei City, Taiwan 5 Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan 6 Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan 7 Department of Anesthesiology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan 8 Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan 9 Center for Evidence-Based Medicine, Taipei Medical University, Taipei, Taiwan 10 Center for Evidence-Based Health Care, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
Keywords dexamethasone; meta-analysis; ondansetron; pediatric; postoperative nausea and vomiting; strabismus Correspondence Ka-Wai Tam and Yih-Giun Cherng, Center for Evidence-Based Health Care, Taipei Medical University-Shuang Ho Hospital, No. 291, Zhongzheng Road, Zhonghe District, New Taipei City 23561, Taiwan Emails: [email protected]; [email protected] Section Editor: Jerrold Lerman Accepted 24 January 2014 doi:10.1111/pan.12374
490
Summary Background: Postoperative nausea and vomiting (PONV) is a common complication after pediatric strabismus surgery. Steroids and ondansetron (a 5-HT3 antagonist) can effectively reduce nausea, vomiting, and pain and thus might be useful agents for the prevention of PONV in pediatric patients. The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the prophylactic effects of dexamethasone and ondansetron on PONV after strabismus surgery in pediatric patients. Methods: A comprehensive literature search was conducted to identify RCTs that investigated the efficacy and safety of intravenous dexamethasone or ondansetron on PONV in pediatric strabismus surgical patients. The primary outcome was the incidence of PONV during the initial 24 postoperative hours. The secondary outcomes were number of patients requiring a rescue antiemetic and complications. Results: We included 13 RCTs that evaluated 2006 patients. In the two studies that compared dexamethasone and placebo treatments, POV occurred in 34.3% (23/67) of the patients in the dexamethasone group and in 68.2% (45/66) of the patients in the placebo group. The difference between the two groups was significant (RR 0.50; 95% confidence interval (CI) 0.34–0.72). Similarly, seven studies that compared ondansetron and a placebo identified a relatively lower incidence of PONV in the ondansetron group (103/277, 37.2%) than in the placebo group (177/270, 65.6%). The difference between the two groups was also significant (RR 0.58; 95% CI 0.43–0.79). The combination of dexamethasone and ondansetron was significantly more effective at reducing the incidence of POV than dexamethasone or ondansetron alone. In all included RCTs, experimental drug-related complications, such as facial flushing and headache, were limited.
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 490–498
Y.-D. Shen et al.
Effects of dexamethasone and ondansetron on PONV
Conclusions: Surgeons and anesthesiologists are recommended to administer the combination of dexamethasone and ondansetron to pediatric patients undergoing strabismus surgery.
Introduction Pediatric strabismus surgery is associated with frequent postoperative nausea and vomiting (PONV). The incidence of PONV after strabismus surgery ranges from 37% to 90% if no prophylactic antiemetic is provided to the patient (1). The major risk factors for PONV in pediatric surgery include the type of surgery (e.g., strabismus surgery and tonsillectomy), age >3 years, duration of anesthesia >30 min, motion sickness, and a personal or family history of PONV (2,3). The additional risk factors for PONV include the surgical techniques used and the number of muscles repaired 4. The proposed underlying mechanisms for frequent PONV after strabismus surgery include the oculoemetic reflex, which is a vagally mediated reflex related to eye muscle manipulation, and alterations in visual perception postoperatively (1,2). In addition to causing discomfort to patients, PONV increases the risk of adverse consequences and, left untreated, can result in complications such as dehydration, electrolyte imbalance, subconjunctival hemorrhage, the loosening of surgical attachments, delayed hospital discharge, and unplanned hospital admission (2). Several studies have showed that preoperative dexamethasone treatment reduces PONV after oral surgery, orthopedic surgery, thyroidectomy, and laparoscopic surgery (5,6). In a double-blind randomized controlled trial (RCT), the incidence and severity of PONV in the first 24 h were significantly lower in the patients treated with dexamethasone than in those administered a placebo (7). Ondansetron is a 5-HT3 antagonist that is commonly administered to pediatric strabismus surgical patients. In a study by Bowhay et al. (8), children treated with ondansetron were associated with
