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GENERAL ARTICLES

Efficacy and Adverse Effects of Prophylactic Antiemetics During Patient-Controlled Analgesia Therapy: A Quantitative Systematic Review

Martin R. Tramèr, MD, DPhil^*, and Bernhard Walder, MD

Divisions of *Anaesthesiology and Anaesthesiological Investigations, Department APSIC, Geneva University Hospital, Geneva, Switzerland

Address correspondence and reprint requests to Martin Tramèr, Division of Anaesthesiology, Department APSIC, Geneva University Hospital, CH-1211 Geneva 14, Switzerland. Address e-mail to martin.tramer{at}hcuge.ch

Nausea and vomiting are frequent adverse effects of patient-controlled analgesia (PCA) with opioids. To identify the optimal prophylactic antiemetic intervention in this setting, we performed a systematic search for randomized trials (MEDLINE, EMBASE, Cochrane library, reference lists, hand-searching, no language restriction) published up to May 1998 that compared prophylactic antiemetic interventions with placebo or no treatment in the postoperative PCA-setting with opioids. Fourteen placebo-controlled trials (1117 patients) with different regimens of droperidol, ondansetron, hyoscine TTS, tropisetron, metoclopramide, propofol, and promethazine were analyzed. One PCA was with tramadol, all others were with morphine. At 24 h, the cumulative incidence of nausea and vomiting without antiemetics was approximately 50%. Droperidol 0.017–0.17 mg/mg of morphine (0.5–11 mg/d droperidol) was statistically significantly more effective than placebo without evidence of dose-responsiveness; the number needed to treat to prevent nausea compared with placebo was 2.7 (95% confidence interval 1.8–5.2), and that to prevent vomiting was 3.1 (2.3–4.8). Compared with placebo, the incidence of minor adverse effects with droperidol was increased with doses >4 mg/d.

Implications: Of 100 patients treated with droperidol added in a patient-controlled analgesia pump with morphine, 30 who would have vomited or been nauseated had they not received droperidol will not suffer these effects. There is no evidence of dose-responsiveness for efficacy with droperidol, but the risk of adverse effects is dose-dependent. There is a lack of evidence for other antiemetics.

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