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LETTER TO THE EDITOR

Universal PONV Prophylaxis in General Anesthesia: Should We Consider Its Immediate Implementation?

Department of Anesthesiology and Pain Management; University Texas Southwestern Medical Center at Dallas; Dallas, Texas; paul.white{at}utsouthwestern.edu (White) Department of Anesthesia; Stony Brook University Hospital – SUNY; Health Science Center L4 #060; Stony brook, New York (Glass)

In Response:

Dürsteler et al.1 suggested that, because ondansetron and droperidol can decrease the analgesic effectiveness of tramadol,2–4 these antiemetics should not be used for routine prophylaxis. We would agree that the literature on chronic drug use would support their statement that the "likelihood to develop a pharmacodynamic drug interaction increases exponentially with the number of drugs administered." However, given the infrequent use of tramadol in the perioperative period for acute pain management (because of its relatively weak analgesic efficacy and high incidence adverse side effects5–8), we would seriously question the clinical importance of this potential drug interaction following a single prophylactic dose of either ondansetron or droperidol.

We would agree with Drusteler et al.1 that dexamethasone9 would be a very logical choice for antiemetic prophylaxis if tramadol is used for acute pain management in the postoperative period. Furthermore, these authors are correct in arguing that, before widespread adoption of our simplified recommendation regarding antiemetic prophylaxis,10 this practice would ideally be subjected to a large scale, prospective clinical trial.

Finally, postoperative nausea and vomiting remains a significant problem for many patients receiving general anesthesia, and is apparently a major concern of many patients scheduled to undergo elective surgical procedures.11 A multimodal approach12 involving a combination of prophylactic antiemetic drugs, adequate hydration and the use of non-opioid analgesic techniques for pain management, remains the best overall solution for minimizing this common side effect in the postoperative period.

REFERENCES

1. Dursteler C, Mases A, Puig MM. Universal PONV prophylaxis in general anesthesia: should we consider its immediate implementation? Anesth Analg 2008;106:1922[Free Full Text]
2. De Witte JL, Schoenmaekers B, Sessler DI, Deloof T. The analgesic efficacy of tramadol is impaired by concurrent administration of ondansetron. Anesth Analg 2001;92:1319–21[Free Full Text]
3. Arcioni R, della Rocca M, Romano S, Romano R, Pietropaoli P, Gasparetto A. Ondansetron inhibits the analgesic effects of tramadol: a possible 5-HT(3) spinal receptor involvement in acute pain in humans. Anesth Analg 2002;94:1553–7[Abstract/Free Full Text]
4. Dursteler C, Mases A, Fernandez V, Pol O, Puig MM. Interaction between tramadol and two anti-emetics on nociception and gastrointestinal transit in mice. Eur J Pain 2006;10:629–39[Web of Science][Medline]
5. Ng KF, Tsui SL, Yang JC, Ho ET. Increased nausea and dizziness when using tramadol for post-operative patient-controlled analgesia (PCA) compared with morphine after intraooperative loading with morphine. Eur J Anaesthesiol 1998;15:565–70[Web of Science][Medline]
6. Rawal N, Allvin R, Amilon A, Ohlsson T, Hallén J. Postoperative analgesia at home after ambulatory hand surgery; a controlled comparison of tramadol, metamizol, and paracetamol. Anesth Analg 2001;92:347–51[Abstract/Free Full Text]
7. Liukkonen K, Santanen U, Pere P, Erkola O, Rautoma P. Peroral tramadol premedication increases postoperative nausea and delays home-readiness in day-case knee arthroscopy patients. Scand J Surg 2002;91:365–8[Medline]
8. Sudheer PS, Logan SW, Terblanche C, Ateleanu B, Hall JE. Comparison of the analgesic efficacy and respiratory effects of morphine, tramadol and codeine after craniotomy. Anaesthesia 2007;62:555–60[Web of Science][Medline]
9. Dursteler C, Miranda HF, Poveda R, Mases A, Planas E, Puig MM. Synergistic interaction between dexamethasone and tramadol in a murine model of acute visceral pain. Fundam Clin Pharmacol 2007;21:515–20[Web of Science][Medline]
10. Glass PS, White PF. Practice guidelines for management of postoperative nausea and vomiting: past, present, and future. Anesth Analg 2007;105:1528–9[Free Full Text]
11. Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999;89:652–8[Abstract/Free Full Text]
12. White PF. Prevention of nausea and vomiting: a multimodal solution to a persistent problem. N Engl J Med 2004;350:2511–2[Free Full Text]

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