Anesth Analg 2004;98:550-551
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000077703.55641.EC
LETTERS TO THE EDITOR
Incomplete Guidelines
Barry L. Friedberg, MD
Volunteer Instructor in Clinical Anesthesia, University of Southern California, Los Angeles, CA
To the Editor:
Congratulations to Gan et al. on the recent PONV guideline publication (1). Why wasn’t the influence of opioids and/or using propofol ketamine (PK) (2) mentioned?
References
- Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003; 97: 62–71.[Abstract/Free Full Text]
- Friedberg BL. Propofol ketamine technique: dissociative anesthesia for office surgery. Anesth Plast Surg 1999; 23: 70–5.
Response
Tong J. Gan,
Tricia Meyer,
Christian C. Apfel,
Frances Chung,
Peter J. Davis,
Steve Eubanks,
Anthony Kovac,
Beverly Philip,
Daniel I. Sessler,
James Temo,
Martin R. Tramèr, and
Mehernoor Watcha
Department of Anesthesiology, Duke University Medical Center, Durham, NC
In Response:
We appreciate the opportunity to respond to the comments by Drs. Friedberg, Butterworth, and White in their separate letters to the editor on our recently published manuscript (1).
To respond to the comments by Dr. Friedberg, the manuscript did specifically address the influence of opioid on postoperative nausea and vomiting (PONV). Opioid is a recognized risk factor for PONV. The use of intraoperative and postoperative opioid was assigned a level of evidence of IIA and IVA, respectively. The use of intraoperative propofol (both for induction and maintenance) significantly reduced the incidence of PONV. The panel gave a level of evidence of IA. In addition, propofol was also effective when used to treat established PONV (level of evidence of IIIB) (1). There is evidence to suggest that ketamine is proemetogenic and when used with propofol, significantly increased the incidence of PONV when compared to propofol alone (2). A recent study found that patients given the combination of propofol and ketamine had faster heart rates, required more pain medication, and had a higher frequency of dreaming in the PACU when compared with propofol/fentanyl group (3).
We appreciated Dr. Butterworth’s comments. Although he is right that consensus guidelines can be commissioned by a recognized professional group of practitioners, they do not have to be exclusively so. There have been many published consensus guidelines that had significant clinical impact that were not commissioned by a professional organization. A few recent examples are referenced (4–8).
Previous guidelines on the management of PONV were broad and did not specifically address issues related to PONV (9). Recent ASA practice guidelines for postanesthetic care did not have sufficient details on the management of PONV (10). This prompted the establishment of this panel to address issues specifically on the management of PONV. The process involved in this consensus project, from identifying members of the panel, the review of the published evidence, discussion of the evidence, and how consensus was reached was clearly outlined in the manuscript. Strict criteria and rigorous standard, as used by other consensus guidelines and the Cochrane system for evidence-based medicine, were followed. A formal working group was established to perform formal literature review. At a specially convened meeting, recommendations and guidelines were discussed, revised, and adopted by a formal vote. In the event where there was no universal agreement, the outcome was reported in the manuscript.
The panel was selected based on their expertise in the area of PONV. We felt that the management of PONV does not only concern anesthesiologists but also the surgeons, pharmacists and nurse anesthetists. Hence a multidisciplinary representation was sought. In addition, pediatric anesthesiologists with significant expertise were also included. It is clearly evident that members of the panel have significant expertise and most are renowned and well-recognized international experts in this field. A Medline search revealed more than 130 peer-reviewed manuscripts on the issue of management of PONV published by the members of the panel. In fact, a number of panel members have been directly involved with previous consensus guidelines and practice parameters established by the American Society of Anesthesiologists, American Society of Health Systems Pharmacists, and other professional organizations.
Although the consensus guidelines on the management of PONV were not commissioned by a professional organization, nevertheless, we are confident that the process to establish such guidelines was strictly and rigorously adhered to and the conclusions are evidence-based and scientifically valid.
In response to Dr. White’s comments, we stated in the manuscript that the sponsor did not have any input in the discussion and the content of the manuscript. Actual or potential conflict of interest was declared by all authors. Although there was industry support for the actual meeting, faculty members were asked to devote a significant amount of their time prior to the meeting in background work for these guidelines, which included searches and reviews of the literature, electronic and telephonic discussions concerning their preassigned topics and questions, and development of a presentation for the topics. All these extremely time-consuming activities were not supported by any sponsor. The meeting was a means to bring together these reviews with the faculty for discussion and consensus.
We stated in the manuscript that published evidence was included up to February 2002. Although we tried to include more recently published evidence, the manuscript by Tang et al. (11) was published in February 2003 and was not in time to be considered.
References
- Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003; 97: 62–71.
- Badrinath S, Avramov MN, Shadrick M, et al. The use of a ketamine-propofol combination during monitored anesthesia care. Anesth Analg 2000; 90: 858–62.[Abstract/Free Full Text]
- Vallejo MC, Romeo RC, Davis DJ, Ramanathan S. Propofol-ketamine versus propofol-fentanyl for outpatient laparoscopy: comparison of postoperative nausea, emesis, analgesia, and recovery. J Clin Anesth 2002; 14: 426–31.[Web of Science][Medline]
- Moore R, Boucher A, Carter J, et al. Diabetes mellitus in transplantation: 2002 consensus guidelines. Transplant Proc 2003; 35: 1265–70.[Web of Science][Medline]
- Davidson J, Wilkinson A, Dantal J, et al. New-onset diabetes after transplantation: 2003 international consensus guidelines. Proceedings of an international expert panel meeting, Barcelona, Spain, 19 February 2003. Transplantation 2003; 75: SS3–24.[Web of Science][Medline]
- Garcia HH, Evans CA, Nash TE, et al. Current consensus guidelines for treatment of neurocysticercosis. Clin Microbiol Rev 2002; 15: 747–56.[Abstract/Free Full Text]
- Strek ME, Antileukotriene Working Group. Consensus guidelines for asthma therapy. Ann Allergy Asthma Immunol 2001; 86: 40–4.[Web of Science][Medline]
- Koeller JM, Aapro MS, Gralla RJ, et al. Antiemetic guidelines: creating a more practical treatment approach [comment]. Support Care Cancer 2002; 10: 519–22.[Web of Science][Medline]
- ASHP Therapeutic Guidelines on the Pharmacologic Management of Nausea and Vomiting in Adult and Pediatric Patients Receiving Chemotherapy or Radiation Therapy or Undergoing Surgery [comment]. Am J Health Syst Pharm 1999; 56: 729–64.[Free Full Text]
- American Society of Anesthesiologists Task Force on Postanesthetic C. Practice guidelines for postanesthetic care: a report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology 2002; 96: 742–52.[Web of Science][Medline]
- Tang J, Chen X, White PF, et al. Antiemetic prophylaxis for office-based surgery: are the 5-HT3 receptor antagonists beneficial? Anesthesiology 2003; 98: 293–8.[Web of Science][Medline]
|
