guidelines on the prevention of postoperative vomiting in children

TheAssociationofPaediatricAnaesthetistsofGreatBritain&Ireland

ContributingAuthors:AlisonSCarrSimonCourtmanHelenHoltbyNeilMortonScottJacobson

LiamBrennanDavidBainesPer‐ArneLönnqvistJackiePope

Spring 2009

GuidelinesonthePreventionofPost‐operativeVomitinginChildren

GuidelinesonthePreventionofPostoperativeVomitinginChildren

ContributingAuthors/MembersoftheGuidelinesGroup: DrAlisonSCarr(Chair)ConsultantPaediatricAnaesthetistPlymouthHospitalsNHSTrustDerrifordHospitalPlymouthPL68DH

HonorarySeniorLecturerPeninsulaCollegeofMedicineandDentistryPlymouthalison.carr@pms.ac.ukDrLiamBrennanConsultantPaediatricAnaesthetistAddenbrookesHospitalCambridgeUniversityHospitalsNHSFoundationTrustHillsRdCambridgeCB20QQDrSimonCourtmanConsultantPaediatricAnaesthetistPlymouthHospitalsNHSTrustDerrifordHospitalPlymouthPL68DHDrDavidBainesClinicalAssociateProfessorHead,DeptofAnaesthesiaTheChildren'sHospitalatWestmeadNSWAustraliaDrHelenHoltbyDirectorofCardiovascularAnaesthesiaHospitalforSickChildrenTorontoCanadaProfessorPer‐ArneLönnqvistSeniorConsultantPaediatricAnaesthesia&IntensiveCareAstridLindgrensChildren’sHospitalKarolinskaUniversityHospitalStockholm,Sweden

ProfesssorDeptofPhysiologyandPharmacologyKarolinskaInstitute17177Stockholm

3 DrNeilMortonConsultantPaediatricAnaesthetistYorkhillChildren’sHospitalGlasgowSeniorLecturerUniversityofGlasgowMsJackiePopePharmacistPlymouthHospitalsNHSTrustDerrifordHospitalPlymouthPL68DHDrScottJacobsonResidentFamilyMedicine,UniversityofNevada,UnitedStatesofAmericaFormerlyClinicalFellowTheHospitalforSickChildrenTorontoCanada

GuidelinesonthePreventionofPostoperativeVomitinginChildrenWewouldliketothankthefollowingpeoplewhoprovidedfeedbackonthedraftguidelinescirculatedtoAPAmembersandlinkmeninFebruary2008:

KarenBartholomew FelicyHoward JanePeutrell

GrahamBell IanJenkins PatrickRadford

BobBingham TrottieKirwan JohnRutherford

EdCarver RosLawson JudithShort

PeterCrean JerryLuntley DavidSteward

MarcDavison RobertLoveridge MarkThomas

ClaudeEcoffey DianaMathioudakis FrancisVeyckemans

ThomasEngelhardt AndyMatthews MadeleineWang

StephenGilbert ReginaMilaszkiewicz KathyWilkinson

JohnGoddard EuniceMorley SimonWhyte

WilliamHinton PeterMurphy AmberYoung

JosefHolzki NigelPereira

5

Contents PageNo.

Keytoevidencestatementsandgradesofrecommendation 6

Introduction 7

Remitoftheguideline

Glossary 8

1.Identifyingchildrenathighriskofpostoperativevomiting(POV) 9

Background 9

A.Patientfactors

Age,historyofPOV,motionsickness,gender,preoperativeanxiety,smoking

9

B.SurgicalFactors

Durationofsurgery,typeofsurgery11

C.AnaestheticFactors

Nitrousoxide,volatileagents,peri‐operativeopioids,anticholinesterases,peri‐operativefluids

13

2.PharmacologicaltreatmentofPOVinchildren

A.Anti‐emeticsforprevention&reductionofPOVinchildren

16

SingleAgents: 16

5HT3Antagonists,Dexamethasone,Metoclopramide,Prochlorperazine,Cyclizine,Dimenhydrinate

CombinationTherapy: 22

Ondansetronanddexamethasone,Ondansetronandothercombinationanti‐emetictherapy,Tropisetron

B.Anti‐emeticsfortreatingestablishedPOVinchildren 24

3.Non‐pharmacologicaltreatmentofPOVinchildren 25

StimulationoftheP6Acupuncturepoint

4.Summaryoffindings&recommendations 26

References 29

GuidelinesonthePreventionofPostoperativeVomitinginChildrenKeytoEvidenceStatementsandGradesofRecommendation:

7

IntroductionPostoperativeVomiting(POV)isanimportantcauseofmorbidityinchildren.ThisreportfortheAssociationofPaediatricAnaesthetistsofGreatBritain&Irelandinvestigatesthecausesofpost‐operativevomitinginchildrenandsummarisestheefficacyoftreatmentsusedtopreventandtreatpostoperativevomitinginchildren.TheguidelineshavebeenpreparedusingSIGNMethodology1drawingtogetheravailableevidenceandrecommendingbestpracticebasedontheavailableevidenceandontheclinicalexperienceoftheguidelinesdevelopmentgroup.

RemitoftheGuidelineTheguidelineseekstoanswerthefollowingquestions:

DraftguidelinesweredistributedtoAPAmembersandLinkmeninFebruary2008forfeedbackandweremadeavailableonthewebsiteoftheAssociationofPaediatricAnaesthetistsofGreatBritain&Irelandforcomment.Theseguidelinesarenowinthefinalversion.Theyhavebeenwritteningoodfaithandwillberevisedasnewinformationbecomesavailable.ShouldthereaderfindanyusefuladditionalcontentpleasecontacttheChairofthePOVGuidelinesgroupbyemailtoinformafuturerevision.


GlossaryNNT:Numberneededtotreat

Thenumberofpatientswhoneedtobetreatedtoreducetheexpectednumberofcasesofadefinedendpointbyone.

Meta‐analysis Astatisticalmethodthatcombinestheresultsofindependenttrialstogiveapreciseestimateoftreatmenteffect.

Casecontrolstudy Astudythatcomparespatientswithanidentifiedoutcomeagainstpatientswithoutthatoutcome,andreviewingthemtoseeiftheyhadanexposureofinterest.

Cohortstudy Astudyinwhichsubjectswhohaveacertainconditionand/orreceiveaparticulartreatmentarefollowedovertimeandarecomparedwithanothergroupwhoarenotaffectedbythatcondition.

Systematicreview Areviewofrelevantliteraturefocusedonaspecificquestionthattriestoidentify,evaluateandsynthesizeallhighqualityresearchevidencerelevanttothatquestion.

Randomisedcontrolstudy

Astudywherebydifferenttreatmentsarerandomlyallocatedtostudyparticipants.Thisattemptstoensuresthatbothknownandunknownconfoundingfactorsareevenlydistributedbetweentreatmentgroups,therebyreducingerrorandbias.

Sensitivity Probabilityofapositivetestamongpatientswithadisease

Specificity Probabilityofanegativetestamongpatientswithoutadisease

Positive(negative)predictivevalue

Theratioofthetruepositives(negatives)dividedbythesumofthetruepositives(negatives)andfalsepositives(negatives).

Oddsratio Theratiooftheoddsofaneventoccurringinonegrouptotheoddsofitoccurringinanothergroup.Anoddsratioof1indicatesthattheconditionoreventunderstudyisequallylikelyinbothgroups.Itprovidesanestimate(withconfidenceinterval)fortherelationshipbetweentwobinary("yesorno")variables.

Confidenceinterval Anindicationofthereliabilityofanestimate.Theconfidencelevelwilldefinehowlikelytheintervalistocontaintheparameter.

Relativerisk Theratiooftheprobabilityofaneventoccurringinatreatmentgroupversusthecontrolgroup.

9

1.IdentifyingChildrenatHighRiskofPostoperativeVomiting

BackgroundPostoperativeVomiting(POV)isapproximatelytwiceasfrequentamongstchildrenasadultswithanincidenceof13‐42%inallpaediatricpatients2,3.SeverePOVcanresultinarangeofcomplicationsincludingwounddehiscence,dehydrationandelectrolyteimbalanceandpulmonaryaspiration4.Itisoneoftheleadingcausesofparentaldissatisfactionaftersurgeryandistheleadingcauseofunanticipatedhospitaladmissionfollowingambulatorysurgerywithresultingincreasedhealthcarecosts5,6.Importantly,noresearchhasfocusedonthechildren’sperspectiveofPOV,andwhethertheyperceivethissymptomwiththesamedistressandloathingasadults7.IdentifyingchildrenathighriskofPOVisbeneficialasprophylacticantiemetictherapycanthenbetargetedatthisgroup.Indiscriminateprophylaxisisprobablyunnecessaryasitisfinanciallycostlyandmayresultinexcessiveadversedrugreactions8.Researchintothisimportantareaishamperedbythedifficultyindiagnosingnauseainyoungerchildren.Hence,vomitingandretchingareusedastheend‐pointsinmostofthepaediatricliteratureonthissubject3.ThemainriskfactorsforPOVinchildrenmaybeconsideredinthefollowingcategories:

• Patient–relatedissues• Surgicalfactors• Anaesthetic(technique&drugsusedinperi‐operativeperiod)

A.PatientFactorsAge

PaediatricpatientshaveahigherincidenceofPOVcomparedtoadultswithchildrenover5yearsofagehavingarounda34‐50%overallriskofvomitingaftersurgery.Thelowestincidenceoccursininfancy(5%incidenceofemesis)whilethepreschoolchildhasa20%riskofvomiting9.Inacohortstudyof1401children<14yearsold,asharpincreaseinPOVriskoccursaroundage3witha0.2‐0.8%peryearincreaseinriskcontinuingintoadolescence10.Thisincreaseinriskaround3yearsofageagreeswiththefindingsofanearlierstudywhichfoundan8%incidenceofPOVinchildren<3yearsold,increasingto29%inchildren>12yearsold11.

2++,

2+

B RiskofPOVincreasesmarkedlyabovethreeyearsoldandcontinuestorisethroughoutearlychildhoodintoadolescence.

TroublesomePOVisrareinchildrenunderthreeyearsoldandpatientsinthisage‐grouprarelyrequireprophylacticantiemeticmedication.


HistoryofPOV

ThishasprovedtobeanimportantriskfactorinthemajorityofstudiesintheadultandpaediatricPOVliteratureandisincludedinalloftheriskscoringsystemstoaidpredictionofPOVthathavebeenpublishedtodate12.Aspecificpaediatriccohortstudyidentified“previousPOV”and“POVinaparentorsibling”asimportantindependentriskfactors10.Acombinedadultandpaediatricstudy(with<10%ofthestudygroupchildren)foundaprevioushistoryofPOVtobethesecondstrongestpredictorofpostoperativenauseaandvomiting13.

2++,

2‐

B AprevioushistoryofPOVisanindependentriskfactorofsubsequentPOVinchildren.

ChildrenwithapasthistoryofPOVshouldbeconsideredforprophylacticantiemeticmedication.

MotionSickness

SeveralstudiesthathavelookedatriskfactorsforPOVinchildrenmentionahistoryofmotionsickness(MS)asapotentialproblem.

Inalargeadultstudy,historyofMSwasidentifiedasastrongpredictorofPOV14howevercautionisrequiredwhenextrapolatingfromadultdata.

OnestudyinchildrenlookedspecificallyatMSasapredictorofPOV.15SeventyconsecutivechildrenwerestudiedundergoingsurgerynothighriskforPOV.

TheoverallincidenceofPOVwas29%.Fourteenchildren(20%)hadahistoryofMS;MS‐positivechildrenweremorelikelytovomitthanthosewhowereMS‐negative(P<0.01).Therewerenoothersignificantvariablesbetweengroups.ThesensitivityofMSasapredictorofPOVwas45%andthespecificity90%,givingapositivepredictivevalueof64.3%andanegativepredictivevalueof80.4%.ItwasconcludedthatMSwasassociatedwithPOVbutitspositivepredictivevaluewasfairlylow.

2+

C AprevioushistoryofmotionsicknessislikelytobeanindependentriskfactorofsubsequentPOVinchildren.

Childrenwithapasthistoryofmotionsicknessshouldbeconsideredforprophylacticantiemeticmedication.

Gender

FemalegenderisastrongriskfactorfrompubertyonwardsinalladultPOVstudies.Adolescentandadultfemaleshaveatwotofour‐foldincreasedPOVriskwhilstprepubescentgirlslackincreasedlikelihoodofPOVcomparedtomales10,11,12,16,17.ThemarkedincreaseinPOVriskatthemenarchesuggeststhatsexhormonesareimplicated.However,initialreportssuggestingthatPOVwasmorecommonduringthefirstweekofthemenstrualcyclehavebeenchallengedinasystematicreview18.

2+adults,

2‐children

D Post‐pubertalgirlshaveanincreasedincidenceofPOVwhichmaybesexhormonerelatedalthoughphaseofthemenstrualcycledoesnotappeartoaffecttheincidence.

11

Post‐pubertalgirlsshouldbeconsideredforprophylacticantiemeticmedication.

Preoperativeanxiety

AlthoughpreoperativeanxietyhasbeenshowntobeaweakriskfactorforPOVinadults,thiswasnotconfirmedinaprevioussmall,butwellconductedstudyinschool‐agechildren19,20.

2‐

Obesity

Earlystudiesfromthe1950sand1960ssuggestedanassociationbetweenobesityandPOVinadults.However,asystematicreviewwithadjustmentformultipleconfoundingfactorsfailedtoconfirmtheseearlierfindings21.ThereisnocomparableevidenceregardingarelationshipbetweenobesityandPOVinchildren.

1+adults

Smoking

AdultsmokersarelesssusceptibletoPOVfromconvincingdatainseveralstudies14,22,23.Nodataonthistopicarepublishedinchildren.ArecentreviewposedtheintriguingquestionifchildrenofsmokershaddecreasedPOVduetopassivesmoking4.

2+adults

B.SurgicalFactors

Durationofsurgery

TheincidenceofPOVincreaseswithlongerdurationofsurgeryandanaesthesiainbothadultandpaediatricstudies10,23.Surgeryundergeneralanaesthesiaof>30minutesdurationwasidentifiedasanindependentriskfactorinalargepaediatricstudywithanoddsratioof3.2510.HalfofthepublishedriskscoringsystemsforPOVinadultsandchildrenincludedurationofsurgeryasanimportantriskfactor17.

2++

C POVincreasessignificantlyifoperativeproceduresunderGAlastmorethan30minutes.

Typeofsurgery

ThestatusoftypeofsurgeryasariskfactorforPOViscontroversial.AlthoughnumerousstudieshaveidentifiedavarietyofproceduresasbeingassociatedwithincreasedriskofPOV,thereisoftenconflictingevidencebetweenstudiesforthesameprocedure.ThisareaofPOVresearchsuffersfromtheproblemofseparating‘true’from‘surrogate’riskfactors3.Forexample,certaintypesofsurgeryassociatedwithhighpostoperativeopioidrequirementsmightbethesurrogateforincreasedPOVriskratherthantheprocedureitself.ThishasresultedinmostoftheestablishedriskscoresforPOVnotincludinganytypeofsurgeryintheirriskmodel10.

GuidelinesonthePreventionofPostoperativeVomitinginChildrenWiththeseconsiderationsinmind,thefollowingproceduresinchildrenhavebeenassociatedwithincreasedPOVrisk:

a.Strabismussurgery

ThisisperhapsthepaediatricsurgicalprocedurethathasthestrongestevidenceofPOVriskwithahighfrequencyofemeticepisodesreportedinasystematicreview(meanincidencelatevomiting59%,butashighas87%inoneoftheincludedstudies)24.ItistheonlysurgicalprocedureincludedintheestablishedpaediatricPOVriskscorewithanoddsratioof4.33,thehighestriskfactorofthefourindependentfactorsidentifiedinthisstudy10.

1++

A ChildrenundergoingstrabismussurgeryareathighriskofPOV.

MinimisingPOVfollowingstrabismussurgeryrequiresamultimodalapproachutilisingantiemetics,dexamethasoneandavoidingearlymobilisationintherecoveryperiod.

b.Adenotonsillectomy

Withoutantiemeticprophylaxis,ahighproportionofchildrenundergoingadenotonsillectomywillexperienceatleastoneepisodeofpostoperativevomiting(89%withoutprophylaxisinoneseries)11,25,26.However,manyofthesestudiessufferfromthedrawbackofthecompoundingeffectofperioperativeopioidadministrationthatmaybeactingasasurrogateriskfactor,asintheabsenceofopioidsinonestudyonly11%ofchildrenvomited27.

1+

A ChildrenundergoingadenotonsillectomyareatincreasedriskofPOV.

MinimisingPOVisessentialforasuccessfulday‐casetonsillectomyprogramme.Scrupuloussurgicaltechniquetodecreaseswallowedblood,avoidanceoflong‐actingopioidanalgesiaandprophylacticantiemeticsanddexamethasonearekeyfactorsinachievingthisgoal.

c.Otoplasty

Otoplastyinchildrenisrecognisedforitsemeticpotentialwithanincidenceofvomitingintheabsenceofantiemeticprophylaxisof60%28.However,surgicaldressings,inparticularpackingoftheexternalearcanal,mayinfluencetheincidenceofPOVinthesepatients29.

2‐

d.OtherproceduresGroinsurgery(herniotomyandorchidopexy)andpenilesurgeryhaveamodestincreasedincidenceofPOV,buttheevidenceisfromolderstudieswithnumerouscompoundingvariablessuchasopioidadministration11,16.

2‐

TheevidencethatproceduresotherthanstrabismussurgeryandadenotonsillectomyareassociatedwithahighincidenceofPOVislesscompelling.However,whentheconsequencesofPOVmaysignificantlyaffectclinicaloutcomese.g.resultinadmissionafterday‐casesurgery,considerationshouldbegiventousingprophylacticanti‐emetics.

13

C.Anaestheticfactors

Avarietyofanaesthetic‐relatedfactorshavebeenimplicatedinproducingincreasedPOVinchildren.However,fewofthesefactorsareincludedinanyofthePOVriskscoringsystemsinthepublishedliteratureforpaediatricpatients4.

Nitrousoxide

Amixedadultandpaediatricsystematicreviewconcludedthatomissionofnitrousoxidereducedtheincidenceofpostoperativevomitingbutnotnauseainhigh‐riskpatientswithaNNTof5.Thereductioninemesis,byavoidingnitrousoxide,wasachievedatthecostofanincreasedriskofintraoperativeawareness30.

Inchildren,avoidingnitrousoxidehasconflictingeffectsonPOV;itproducesasmallreductioninearlyPOVfollowingdentalsurgerybutnotaftergrommetinsertionwithoutanydifferenceinlatePOVrateswitheitherprocedure31,32.InasmallRCT,therewasnodifferenceinPOVratesinpaediatricT&Aspatientswhoreceivednitrousoxidecomparedtothosewhodidnotreceivetheagent.33

1+,

2‐

C TheuseofnitrousoxidedoesnotappeartobeassociatedwithahighriskofPOVinchildren

NitrousoxidemaybeusedforanaesthesiainchildrenwithoutincreasingtheincidenceofPOV.

Volatileagents

Althoughmodernvolatileagentsarelessemetogenicthanolderagents(e.g.ether),thereisevidencethatvolatileagentsmaysignificantlycontributetoearlyPOVparticularlyinhigh‐riskpatients.Thereisalsoastrongdose‐responserelationshipbetweenPOVanddurationofexposuretovolatileagents34.Volatileagentsarefarmoreemetogenicwhenusedformaintenanceofanaesthesiawhencomparedtopropofolmaintenanceinalargemeta‐analysis35.Thereislittleevidencethatanyofthemodernagentsislessormoreemetogenicthantheothers34,35.

1++,1+

A UseofvolatileanaestheticagentsisassociatedwithincreasedriskofemesisparticularlyinchildrenwhohaveotherriskfactorsforPOV.

ItisrecommendedthattotalintravenousanaesthesiashouldbeconsideredwhenchildrenwhoareathighriskofPOVundergosurgerythathasahighriskofproducingPOV.

Peri‐operativeopioids

Despitethewidelyheldbeliefthatperi‐operativeopioidadministrationisstronglyimplicatedinincreasedPOV,theevidencefromtheliteratureislesscategorical.

IntraoperativeopioiduseinchildrenintwolargestudieswasassociatedwithreducedoronlyslightincreasedincidenceofPOV10,34,whereaspostoperativeadministrationinboththesestudieswasassociatedwithincreasedPOVriskwith

1+,1‐

GuidelinesonthePreventionofPostoperativeVomitinginChildrenoddsratiosof1.64and2.3respectively.

Conversely,theuseofperioperativemorphineinchildrenisassociatedwithincreasedPOVriskforarangeofproceduresincludingadenotonsillectomy,strabismussurgeryanddentalsurgery27,36,37,38

AlthoughadministrationofperioperativeopioidsisincludedinhalfofthepublishedadultPOVriskscores,opioidusewasnotregardedasanindependent,statisticallysignificantpredictorofPOVinthemostwidelyquotedpaediatricPOVriskscoringsystem.11

B UseofopioidsmaybeassociatedwithincreasedriskofPOVparticularlyiflonger‐actingagentsareusedinthepostoperativeperiod

TheanaesthetistshouldtrytoachievesatisfactorypostoperativeanalgesiawithouttheuseofopioidswheneverpossibleifPOVistobeminimised,particularlyinhighriskpatients.

Useofregionalandlocalanaesthesiatechniquesarerecommendedwhereappropriatetoreducetheneedforopioids.

Useofanticholinesterasedrugs

AntagonismofneuromuscularblockadehasbeenassociatedwithincreasedriskofPOV.Inasystematicreviewofthissubjectinamixedadultandpaediatricpopulation(25%children),higherdoseneostigmine(>2.5mgsinadults)wasassociatedwithasignificantlyincreasedriskofPOV,althoughthestudydidnotanalysethepaediatricandadultpatientsseparately39.

2‐

D UseofanticholinesterasedrugsmayincreasePOVinchildren.

InsituationswhereachildisathighriskofPOV,anaesthesiawithoutmusclerelaxantsshouldbeconsideredtoavoidtheriskofrequiringreversalofneuromuscularblockade.

Peri‐operativeFluids

Forminorsurgicalprocedures,givinglargevolumesofIVcrystalloidintraoperativelyreducedPOVinchildrenafterstrabismussurgeryinthefirst24hoursaftersurgery.40Onehundredchildrenwererandomlyassignedtoreceive30ml∙kg−1∙h−1(“superhydrationgroup”)or10ml∙kg−1∙h−1(controlgroup)oflactatedRinger'ssolutionintra‐operatively.Nauseaandvomitingoccurredin11(22%)ofpatientsinthesuperhydrationgroupand27patients(54%)ofthecontrolgroup(P=0.001).Inastudyofchildrenadmittedfordaycasesurgery,989children(aged1month‐18years)wererandomisedtotwogroups:mandatorydrinkersandelectivedrinkers.41The464mandatorydrinkershadtodemonstrateabilitytodrinkclearliquidswithoutvomitingpriortodischargewhereas525electivedrinkerschosewhethertheywishedtodrinkornotbeforedischarge.AllpatientsreceivedadequateIVfluidstosupplyacalculated8‐hfluiddeficitpriortodischarge.Theincidenceofvomitingdidnotdifferbetweengroupsintheoperatingroom,thepost‐anesthesiacareunitorafterdischargefromhospital.Inthedaysurgeryunit,

1+,

2+

15 only14%electivedrinkersvomitedcomparedto23%mandatorydrinkers(P<0.001).Themandatorydrinkersstayedlongerthanelectivedrinkersinthedaycareunit(P<0.001).Nochildrenwereadmittedtohospitalwithpersistentvomiting.

Thereisalsoevidencethatwithholdingoralfluidsfromchildrenpost‐operativelyreducedtheincidenceofvomitinginhospitalafterdaycasesurgery.42Inastudyof317children,overallPOVwasreducedfrom56%to38%(P=0.004)bywithholdingoralfluids:Althoughin‐hospitalvomitingwasreducedfrom38%to21%(P=0.003),therewasnosignificantreductioninpost‐dischargevomiting.

1+

B Peri‐operativeIVfluidsmayreducePOVinchildrenafterdaycasesurgery.

POVinchildrenmaybeincreasediftoleranceoforalfluidsismandatorybeforedischargefromdaycasesurgery.

Intra‐operativefluidsmayreducePOVinchildrenafterdaycasesurgery.

Oralfluidsshouldbeofferedtochildrenwishingtodrinkbeforedischargeafterdaycasesurgerybutshouldnotbemandatory.


2.PharmacologicalTreatmentofPost‐operativeVomitinginChildren

Inthissection,theevidencefortheefficacyofcommonlyusedanti‐emeticsinreducingpost‐operativevomitinginchildrenisreportedandrecommendationmadeforpreventingPOVinchildren.InadditionrecommendationsaremadeontreatingestablishedPOVinchildren.

A.Anti‐emeticsforPrevention&ReductionofPost‐operativeVomitinginChildren

5HT3Antagonists

5HT3antagonistsareeffectiveanti‐emeticsinchildren.Therearealargenumberofstudiesavailableexaminingtheincreasingnumberoftheseagentsavailableaswellassomeoftheotherissuesrelatedtoadministrationof5HT3antagonists.Ondansetron

OndansetronislicensedforuseintheUKinchildrenandyoungpeople(aged2‐18years)forreducingpost‐operativevomitingandiscommonlyused.Theproductlicenceisforondansetron0.1mg.kg‐1uptoamaximumof4mg.Undesirableeffectsassociatedwiththeuseofondansetroninchildrenarerareandclinicallyunimportant.Arecentpapersuggeststheremaybeapossiblereductionofanalgesiceffectsofparacetamolby5HT3antagonists.

43Thiseffectmaybeimportantbuthasnotyetbeenconfirmedinchildrenanddoesnotappeartobereflectedbyclinicalexperiencereportedsofar.

WhatistheoptimaldoseofondansetronforreducingPOVinchildren?

Theefficacyofondansetronwasstudiedindoseranges0.05to0.3mg.kg‐1andadoserelatedresponsewasdemonstrated44‐46.TheoveralloddsratioforPOVwas0.3644.Thesummaryoddsratioper0.1mg.kg‐1increaseindosewas0.43.

Subgroupanalysisofthepaediatricdata(1688children)showedthatinthepreventionofearlyvomiting,dosesof0.10and0.15mg.kg‐1wereclinicallyeffectivewithNNTof4.68and2.82respectively46.Inthepreventionoflatevomiting,0.10and0.15mg.kg‐1gaveNNTof5.35and3.67respectively.

Alowerdoseof0.05mg.kg‐1hadanoddsratiowithconfidenceintervals0.49to11.39andwasconsiderednoteffective47.

1++

A OndansetronisaclinicallyeffectiveantiemeticinchildrenundergoingproceduresassociatedwithahighriskofPOV.Thereisadoserelatedresponsewiththeoptimaldosebeing0.15mg.kg‐1.

17

ChildrenatincreasedriskofPOVshouldbegivenondansetron0.15mg.kg‐1.OndansetroncanbeusedasasingleagenttopreventearlyandlatePOV.

Whatroutesofadministrationareeffectiveforondansetron?Inameta‐analysisofchildrenundergoingtonsillectomy,studiesusingbothoralandintravenousondansetronwereincluded.TherewasnoevidencethatIVwasmoreeffectivethantheoralpreparationinchildrenundergoingtonsillectomy43.OneRCTof140childrenfoundoralondansetron0.15mg.kg‐1reducedPOVsignificantlywhereasanoraldoseof0.075mg.kg‐1wasnomoreeffectivethanplacebo48.Anoraldispersiblepreparationofondansetron4mgwaswelltoleratedbychildrenandefficacious49.

1+

A TheoralrouteisaseffectiveastheintravenousroutefortheadministrationofondansetroninpreventingPOVinchildren.

Theoralroutemaybeconsideredanalternativerouteforondansetronadministrationinsituationswhereintravenousaccessisnotavailable.

WhenisthebesttimetoadministerondansetrontoreducePOV?

InaRCTof120children,administeringondansetron0.10mg.kg‐1atthebeginningorendofsurgerymadenodifferencetoratesofearly,lateortotalPOV48.

ArecentCochranereviewofalladultandpaediatricPOVstudiesalsofoundnoevidencethattheriskofPOVdifferedingroupsgivenondansetronbeforeinduction,atinduction,intra‐operativelyorpost‐operatively50.

1+,1++

A Thereisnoevidencedemonstratingabenefitoftimingondansetronadministrationinchildrenwithrespecttothetimeofsurgery.

Ondansetronmaybegivenbeforeinduction,atinduction,intra‐operativelyorpost‐operatively.

Howdoestheefficacyofondansetroncomparetootheranti‐emeticsforreducingPOVinchildren?

Ondansetronhashighefficacywhencomparedwithotheranti‐emetics.

Inameta‐analysisexaminingstudiescomparingondansetronwithmetoclopramide(6studies)ordroperidol(9studies)inchildrenundergoingdifferenttypesofsurgery,thepooledoddsratioshowedondansetrontobemoreeffectivethandroperidol,OR0.49,andmetoclopramide,OR0.3345.

InasingleRCTof130children(45pergroup)ondansetronanddexamethasone(1mg.kg‐1)werecomparedtoplacebo.BothondansetronanddexamethasonesignificantlyreducedtotalPOVandearlyPOVeffectively.However,inlatevomiting,ondansetrondidnotreducePOVcomparedtoplacebowhereasdexamethasonewasclinicallyeffectivecomparedtobothplaceboandtoondansetron51.

1+


A OndansetronismoreclinicallyeffectivethandroperidolormetoclopramideinpreventingPOVinchildren.OndansetronisequallyeffectivetodexamethasoneforearlyPOValthoughthelattermaybemoreeffectiveinreducinglatePOV.

OndansetronshouldbeconsideredasafirstlinetreatmentinchildrenwithahighriskofPOV.Combinationtherapywithasecondagentmayimproveitsefficacy(asdetailedbelow).

TropisetronTropisetronisaneffectiveanti‐emeticforPOVinchildren.ItdoesnotyethaveaproductlicenseforuseinchildrenintheUK.

Twostudiesusingtropisetron0.1‐0.2mg.kg‐1inchildrendemonstrateanoveralloddsratioof0.15forPOVwithnocleardoserelatedresponse44.Onestudyof120childrenfoundnodifferenceinoutcomewithearlyorlateadministrationoftropisetron52.Anotherstudyexaminedtheadditionofdexamethasonetotropisetronandfoundthatoverallvomitingwasreducedfrom53%(tropisetron0.1mg.kg‐1)to26%(tropisetron0.1mg.kg‐1+dexamethasone0.5mg.kg‐1)53.However,thisreductionwasnotdetecteduntilafter4hourspost‐operatively.

1+

A Tropisetronisaneffectiveanti‐emeticinchildrenathighriskofPOVandthisefficacyisincreasedbytheadditionofdexamethasone.

AlthoughtropisteroniseffectiveinreducingPOVinchildren,itisnotlicensedforuseinchildren.OndansetronshouldbeusedforreducingPOVinchildren.

GranisetronThreestudiesoftheefficacyofgranisetroninchildrenundergoingtonsillectomydemonstrateanoddsratioforPOVof0.11usingadoserangeof10‐80mcg.kg‐1.Thereisnocleardoserelatedresponseasseenwithondansetron44.FurthermoreCochranemeta‐analysissuggeststhattheeffectofgranisetrononreducingPOVmaybeoverestimatedbythesepapers.

1+

A Granisetronmaybeaneffectiveanti‐emeticforPOVinchildren.

MoreevidenceisrequiredontheefficacyofgranisetroninreducingPOVinchildren.

DolasetronInadosefindingstudyin204childrenundergoingdaycasesurgery,dolasetron350mcg.kg‐1wasaseffectiveatpreventingPOVasondansetron100mcg.kg‐1.54Onestudyon150dexamethasone‐pretreatedchildrenundergoingtonsillectomyshowed

1+

19 anoddsratioof0.25forPOVinchildrengivendolasetron55.

Acuteelectrocardiographicchangesinchildrenandadolescentsoccurverycommonlywithdolasetron.(http://emc.medicines.org.uk)ThereisevidencetosuggestthatacutechangesinQTcintervalaregreaterinchildrenthaninadults.Individualcasesofsustainedsupraventricularandventriculararrhythmias,cardiacarrestandmyocardialinfarctionhavebeenreportedinchildrenandadolescents.Theuseofdolasetroninchildrenandadolescentsunder18yearsoldiscontraindicated.

A Dolasetroniscontraindicatedforuseinchildrenandadolescentsunder18yearsold.

DolasetroniscontraindicatedforpreventionofPOVinchildren.

DexamethasoneDexamethasonehasincreasinglybecomerecognisedasaneffectiveanti‐emeticinchildrenonitsownandincombinationwith5HT3antagonists.

WhatistheoptimaldoseofdexamethasoneforreducingPOVinchildren?

Todate,therehasbeenonesystematicreviewondexamethasoneforpreventionofPOVonmixedadultandpaediatricstudies56.Analysisofthe7paediatricstudieswasnotreportedseparately.Dexamethasone1.0‐1.5mg.kg‐1versusplacebo(3trials)hadaNNTof10inpreventingearlyPOV(<6hr)andaNNTof3.2inpreventinglatePOV.

ACochranedatabasereviewin2003examiningchildrenundergoingtonsillectomyconcludedthatchildrengivenasingledoseofIVdexamethasone0.15to1.0mg.kg‐1

(max8‐25mg)werehalfaslikelytovomitinthefirst24hoursaftertonsillectomy(RelativeRisk=0.54,95%CI0.41‐0.74)57.RoutineuseofdexamethasoneinchildrenwasassociatedwithaNNTof4.

Adosefindingstudyofdexamethasone(0.25to1.0mg.kg‐1)in168childrenundergoingstrabismussurgerycomparedtoplaceboidentifiednoadditionalbenefitofusingdosesgreaterthan0.25mg.kg‐1.Forallgroupsstudied,therewasanNNTof2.2‐2.7.Inallgroupsreceivingdexamethasonetherewasnoevidenceofsideeffectsrelatingtoincreasedbloodsugarsorincreasedwoundinfectionrates58.

IVdexamethasonemaycauseperinealwarmthandshouldbeinjectedslowlyintheconsciouschild.Dexamethasonemayalsocauseinsomnolenceifgivenlateintheevening.Thereisnolong‐termfollow‐upstudyevaluatingeffectsofdexamethasoneontheimmunesysteminchildren.

ThreestudieshaveshownlowerdosesofdexamethasoneprovidesimilarclinicallysignificantpreventionofPOV59‐61:

Onestudyin140childrenuseddexamethasone150mcg.kg‐1(max8mg)andfoundanoverallreductioninPOVfrom71%to40%59.

1+,1++


Anotherstudycomparedlowdosedexamethasone(50mcg.kg‐1to250mcg.kg‐1)andfoundasignificantreductioninPOVevenwithdosesassmallas50mcg.kg‐160.TheNNTrangeforallgroupswas2‐2.9.

Inanotherstudy.125childrenundergoingadenotonsillectomyortonsillectomywereenrolledinadose‐escalatingstudyofdexamethasone:0.0625,0.125,0.25,0.5,or1mg.kg‐1,maximumdose24mg61.Therewasnodose‐escalationresponsetodexamethasoneforpreventingvomiting,reducingpain,shorteningtimetofirstliquidintake,ortheincidenceofvoicechange.Thelowestdoseofdexamethasone(0.0625mg.kg‐1)wasaseffectiveasthehighestdose(1.0mg.kg‐1)forpreventingPOVorreducingtheincidenceofothersecondaryoutcomes.Theauthorsconcludethereisnojustificationfortheuseofhigh‐dosedexamethasoneforthepreventionofPONVinthiscohortofchildren.SeveralreportsofacutetumourlysissyndromehavebeendescribedafterdexamethasonehasbeengiventoasusceptiblepatientindosesusedinpreventingPOV.62‐64TumourLysisSyndromeisapotentiallylethalconditionthatoccursparticularlyinhaematologicalmalignanciesaftertreatmentwithcytotoxictherapies.Dexamethasonehasinducedacutetumourlysisinpatientswithnon‐Hodgkinslymphoma62andacuteleukaemia.63‐64

A DexamethasonegivenalonereducestheriskofPOVinchildren.ItappearstobeparticularlyeffectiveinpreventinglatePOV(>6hr).

Adoseofdexamethasone150mcg.kg‐1providesgoodreductioninPOVwithnoadverseeffects.Dosesaslowasdexamethasone62.5mcg.kg‐1areefficaciousinreducingPOVinchildren.Dexamethasoneshouldnotbeusedinpatientsatriskoftumourlysissyndrome.

Metoclopramide

Metoclopramideindosesrangingfrom0.15mcg.kg‐1to0.25mcg.kg‐1hasbeenshowntoreducePOVinchildreninsomestudiesonly65‐67.Overall,thereislittlesupportintheliteraturefortheuseofmetoclopramideasananti‐emeticinchildrenfortheprophylaxisofpost‐operativevomitinginthedosestested(usually0.25mcg.kg‐1)15,45,68‐72.

Theextrapyramidaleffectsassociatedwithmetoclopramidearemorecommoninchildrenandhaveoccurredindosesusedtotreatpost‐operativevomiting.73

1+,1++

A Metoclopramideindosesof0.25mcg.kg‐1orlessdoesnotreliablyreducePOVinchildren.Furtherdose‐responsestudiesofmetoclopramidearerequiredtoseeifimprovedefficacyforpreventingPOVinchildrencanbeachievedathigherdoses.

Metoclopramideisnotareliableanti‐emeticinchildrenandisnotrecommendedforreducingPOVinchildren.Theroleofmetoclopramideinthetreatmentofestablishedpost‐operativevomitingrequiresfurtherinvestigation.

21

Prochlorperazine

Theanti‐emeticeffectofprochlorperazineinchildrenhasnotbeendetermined.Side‐effectshavebeenreportedwhenchildrenhavebeengivenprochlorperazine74.Thesearepredominantlyneurological,independentofdoseanddisappearedspontaneouslyafterdiscontinuationofthedrug.Impairedconsciousness,dyskinesia,pyramidalsignsandhypertonuswerethemainneurologicalmanifestations.

4

D ThereisnoevidenceintheliteraturefortheefficacyofprochlorperazineforreducingPOVinchildren.

ProchlorperazineisnotrecommendedforpreventionofPOVinchildren.

Cyclizine

Cyclizineisapiperazineantihistamineavailableover‐the‐counterandbyprescriptionintheUK,Canada,USandAustralia.InCanadatheuseofcyclizineforpatientsunder6yearsoldisoff‐label.Ithasbeenreportedasadrugwithpotentialforabuse75.Thereareonly2studiesontheuseofcyclizinefortreatingPOVinchildrenandneitherhadpositivefindings76‐77.Ithasbeenconcludedthatthereisnodetectableanti‐emeticeffectwithcyclizineandfurthermoretherewassignificantpainoninjection73.

1+

AThereiscurrentlynoevidencetosupporttheuseofcyclizineforPOVinchildreneitherforprophylaxisorfortreatment.

CyclizineisnotrecommendedforreducingPOVinchildren.

DimenhydrinateDimenhydrinateisthetheoclatesaltofdiphenhydramine.DimenhydrinateisavailableinCanada,theUSandAustraliabothover‐thecounterandbyprescription.ItisnotavailableintheUK.Itcanbegivenorally,intravenouslyandasasuppository.Itwassynthesizedwiththeintentionofantagonizingthemoderatelysedativeeffectsofdiphenhydraminewiththemildlystimulanteffectsoftheophylline.Howeversedationanddrymouthandotheranti‐muscarinicsideeffectsdooccur.SeriousadversereactionsappeartoberarealthoughitisaweaknessofbothpublishedRCTsandmeta‐analysesthatthereislittledocumentationofsideeffects.

Twosystematicreviewsreportondimenhydrinate44,78.Inasystematicreviewandmeta‐analysisofanti‐emeticprophylaxisforchildrenundergoingtonsillectomy,dimenhydrinatewasnoteffectiveinthedosesstudied44.Inanothersystematicreview,theeffectivenessofdimenhydrinateforprophylaxisofpostoperativenauseaandvomitingwasreportedinbothadultsandchildren78.ThepaediatricstudieswereanalysedasasubgroupandtheNNTforchildrenwasreportedas4.76

1+,1++

GuidelinesonthePreventionofPostoperativeVomitinginChildrenforIV/IMadministrationand3.57forrectaladministrationofasingleequivalentdoseofdimenhydrinatehowevertheconfidenceintervalsarewide(2.56‐33.3and1.92‐20).

InasmallRCTof100childrenundergoingreconstructivesurgeryforburns,dimenhydrinate0.5mg.kg‐1wasfoundtobeasclinicallyeffectiveasondansetronbutmuchmorecosteffective79.Dimenhydrinate0.5mg.kg‐1hasalsobeenshowntobeeffectiveinstrabismussurgery80.Therearefewseriousside‐effectsandthecostbenefitratioisveryadvantageous.

A Insummary,thereisevidencetosupporttheuseofdimenhydrinateasprophylaxisinchildrenatmoderateorhighriskofpostoperativenauseaandvomitingexceptfortonsillectomy.

Dimenhydrinate0.5mg.kg‐1maybeusedtoreducePOVinchildrenexceptforchildrenundergoingtonsillectomy.

Therearenostudiesexaminingtheuseofdimenhydrinatetotreatpostoperativevomitingbutnonethelessitiscitedasrescuetherapyinonereviewarticleonperi‐operativenauseaandvomitinginchildren81.

4

DDimenhydrinatehasbeenusedforrescuetherapyinestablishedPOVinchildren.

DimenhydrinatemaybeusefulforrescuetherapyinestablishedPOVinchildren.

CombinationTherapy

OndansetronandDexamethasone

ThreerandomizedcontrolstudieshaveexaminedtheefficacyofondansetroncombinedwithdexamethasoneforpreventionofPOV82‐84.

Twolargestudiesdemonstratedthatondansetron50mcg.kg‐1combinedwithdexamethasone150mcg.kg‐1wasmoreeffectiveatpreventingPOVinchildrenundergoingstrabismussurgerythanondansetron150mcg.kg‐1aloneordexamethasone150mcg.kg‐1alone82,83.Astudyof193childrenundergoingstrabismussurgerycompareddexamethasone(150mcg.kg‐1)alonetodexamethasone(150mcg.kg‐1)plusondansetron(50mcg.kg‐1)82.Theadditionofondansetronreducedoverallvomitingfrom23%to5%.Astudyof200childrenundergoingstrabismussurgerycomparedondansetron(150mcg.kg‐1,maximumdose8mg)alonetodexamethasone(150mcg.kg‐1)plusondansetron(50mcg.kg‐1)83.TheincidenceofPOVwassignificantlylessinthecombinationgroup(9%)thanintheondansetrononlygroup(28%).

Inanotherstudynodifferencebetweentreatmentswasdetectedbetweenseveralcombinationtreatmentgroupscontainingondansetronandarangeofdexamethasonedosesandplacebo84.Thiswasattributedtotheparticularlylowbaselineincidenceofvomitingintheplacebogroup.

1+

23

A OndansetroncombinedwithdexamethasoneincreasestheeffectivenessinpreventingPOVinchildren.

InchildrenathighriskofPOV,combinationtherapyofondansetronanddexamethasoneshouldbegiven.IVOndansetron50mcg.kg‐1andIVdexamethasone150mcg.kg‐1shouldbegiventochildrenscheduledforadenotonsillectomyorstrabismussurgery.

Ondansetronandothercombinationanti‐emetictherapy

Ameta‐analysisexamininganti‐emeticcombinationtherapyincluded8paediatricstudies85.Althoughnoseparatedataoranalysiswaspresented,ondansetroncombinedwithdroperidolordexamethasonewasmoreeffectiveinpreventingPOVthanondansetronalone.

1+

A OndansetronwhencombinedwithdroperidolordexamethasoneismoreeffectiveinpreventingPOVthanondansetronalone.

Combinationanti‐emetictherapyshouldbeusedforchildrenathighriskofPOVorwheresingleagenttherapyhasfailedpreviously.Ondansetronanddexamethasoneisthemosteffectivecombinationofanti‐emeticsforreducingPOVinchildrenandisrecommendedforsituationsathighriskofPOV.

TropisetronandDexamethasone

Inastudyof132children,tropisetron0.1mg.kg‐1alonewascomparedtotropisetron0.1mg.kg‐1withdexamethasone0.5mg.kg‐1forpreventionofPOVaftertonsillectomy86.AdditionofdexamethasonereducedtheoverallincidenceofPOVfrom53%to26%.Thisreductionwasnotevidentatlessthan4hours.

1+,1++

A Tropisetronplusdexamethasoneismoreeffectivethantropisetronaloneforthepreventionofpostoperativenauseaandvomitinginchildrenundergoingtonsillectomy.

AlthoughIVtropisetronandIVdexamethasoneiseffectiveinreducingPOVinchildren,tropisetronisnotlicensedforuseinchildren.OndansetronanddexamethasoneshouldbeusedforreducingPOVinchildrenathighriskofPOV.


B.Anti‐emeticsforTreatingEstablishedPost‐operativeVomitinginChildren

Therearefewertrialsofefficacyofanti‐emeticsincontrollingestablishedPOVintherecoveryroominadultsandevenfewerinchildren87,comparedtothemultitudeoftrialsonprophylaxisofPOV.

Thereisonlyonetrialofasingledoseofondansetron(0.1mg.kg‐1)versusplaceboformanagingestablishedPOVinchildrenwhohavenotreceivedprophylactictherapy88:childrenexperiencingtwoemeticepisodeswithin2hofdiscontinuinganaesthesiaweregivenIVondansetron0.1mg.kg‐1upto4mg(n=192)orplacebo(n=183).Theproportionofchildrenwithnoemeticepisodesandnouseofrescuemedicationwassignificantlygreater(P<0.001)intheondansetrongroupcomparedwithplaceboforboth2‐and24‐hperiodsafterstudydrugadministration(78%oftheondansetrongroupand34%oftheplacebogroupfor2h;53%oftheondansetrongroupand17%oftheplacebogroupfor24h).Conclusionswereasingledoseofondansetron(0.1mg.kg‐1upto4mg)iseffectiveandwelltoleratedinthepreventionoffurtherepisodesofpostoperativeemesisinchildrenafteroutpatientsurgery.

Doserangingstudiesofasingledrugandcomparativestudiesofdifferentdrugsareabsentinthispatientpopulationinthesecircumstances.

Animportantstudyof428patientswhodevelopedPOVdespiteprophylaxiswithondansetron4mgIVdemonstratedthatgivingaseconddoseofondansetronwasaseffectiveasgivingplacebo89.Thisstudysuggeststhatifprophylaxiswithonedrugfails,aseconddrugfromanotherclassshouldbeusedforrescue.

1+

1+

B IVOndansetronmaybeeffectivefortreatingestablishedPOVinchildrenwhohavenotalreadyreceivedondansetron.

OndansetronisunlikelytobeeffectiveforestablishedPOVoccurringafterondansetronhasbeenadministered.

IVOndansetron0.15mg.kg‐1shouldbeusedtotreatestablishedPOVinchildrenwhohavenotalreadyreceivedondansetron.

Forchildrenwhohavealreadybeengivenondansetronprophylactically,itisrecommendedthatasecondantiemeticfromanotherclassshouldbegiven,suchasIVdexamethasone0.15mg.kg‐1injectedslowly.

25

3.Non‐PharmacologicalTreatmentofPost‐operativeVomitinginChildren

Avarietyofdifferentnon‐pharmacologicaloptionshavebeendescribedinordertopreventortreatPONVinchildrenbutthenumberofpublicationsaswellaspatientnumbersandstudydesignareofteninsufficienttoallowforameta‐analysisorstructuredreview(i.e.typeofbandagingfollowingbat‐earsurgery90).Thus,thissectionwillonlyfocusonthedifferenttypesofstimulationoftheP6acupuncturepoint(acupuncture,acupressure,orelectrical/laserstimulation)thathasbeenreportedinchildren.

StimulationoftheP6AcupuncturePointAmeta‐analysisin1999concludedvarioustypesofacustimulationinadultswereequallyeffectivecomparedtoanti‐emeticdrugsinpreventingvomitingaftersurgeryandthatsuchnon‐pharmacologicalternativesweremoreeffectivethanplaceboinpreventingPONVintheearlypostoperativeperiod91.Nobenefitwasfoundwithinthepaediatricpopulationinthisreview.

Sincethentwofurtherreviewshavebeenpublishedthatincorporatemorerecentpublicationswithinthisfield.InalargeCochranereportfrom2004(up‐dateofthe1999meta‐analysisabove,26trials,n=3,347)92acustimulationwasagainfoundtobeofbenefitinadultscomparedtocontrol.InthisCochranereport,acustimulationwasalsofoundtobeofbenefitinchildreninreducingtheincidenceofnauseaandalsopointingtoaborderlinesignificantreductioninvomitingcomparedtoshamtreatment.Whencomparedtoanti‐emeticdrugsusedforpreventionofPOV,acustimulationappearedtobeequallyeffective.

Recentlyameta‐analysisfocusingonchildrenincludedtwelveRCTs,mainlyperformedinthecontextofhigh‐risksurgery(e.g.adenotonsillectomyorstrabismussurgery)93.Themeta‐analysisshowedthatallacustimulationmodalitiesreducedvomiting(RR=0.69,95%CI:0.59‐0.80,p<0.0001)andnausea(RR=0.59,95%CI:0.46‐0.76,p<0.0001)comparedtonon‐activecontrol.Inthreetrialswhereacustimulationhadbeencomparedtoanti‐emeticdrugstherewasnodifferenceinreducingvomitingbetweengroups(RR=1.25,95%CI:0.54‐2.3,p=0.60).Comparingthedifferentmodalities,acupuncturewasfoundmoreeffectivecomparedtoacupressureandelectricalstimulation.

1+,1++

A CurrentevidencebasesupportsacustimulationreducingPOVcomparedtothenon‐activecontrolsituation.AcustimulationappearstobeequallyeffectiveinpreventingPOVasanti‐emeticdrugsinchildren.

Theuseofacustimulationcanbeconsideredasanalternativetreatmenttoanti‐emeticmedicationsforsurgerywherethereisahigh‐riskPOVinchildren.


4.SummaryofFindings&Recommendations

PatientFactorsassociatedwithahighriskofPOV:

SurgicalproceduresassociatedwithahighriskofPOV:

27 AnaestheticfactorsaffectingtheincidenceofPOVinchildren:

SummaryofrecommendationsforpreventionofPOVinChildren:


SummaryofrecommendationsfortreatmentofestablishedPOVinChildren:

29

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