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[每周一问]No.7-Treatment of PONV
This week we'll be discussing one of the more frequent complications associated with anesthesia and surgery, postoperative nausea and vomiting. Today, we'll focus on treatment of PONV.
1.  Is the prophylactic use of antiemetics justified?
2.  Does effective single agent therapy exist?
3.  Can steroids reduce the incidence of PONV?
4.  What are some nonpharmacologic therapies to prevent PONV?
1.  预防性使用镇吐药物是否恰当？
2.  有效的单一治疗药物是否存在？
3.  类固醇（Steroids）能否降低PONV的发生？
4.  抑制PONV的的非药物措施有哪些？

 

[每周一问]No.7-Treatment of PONV
1.预防性使用镇吐药物是否恰当？
大多数学者认为预防性使用镇吐药物并非恰当，因为大多数患者并不出现PONV，并且，即使出现PONV，大多数患者症状轻微。Scuderi等研究发现，虽然PONV的发生率降低了，但是没有证据表明出院时间、非预料性入院、患者满意度以及恢复正常工作时间得到提高。此外，一些常规给于的镇吐药物有明确的副作用，同时部分新药物，特别是抗组胺药物、抗5-羟色胺能药物价格昂贵。
2.有效的单一治疗PONV的药物是否存在？
由于与PONV产生相关的各种刺激和受体的数量和种类众多，现在还没有一个单独的药物能完全阻止或治疗PONV，因此，当前治疗PONV最有效的方法是多种不同机制的药物的联合使用。最近的研究表明，NK1受体有可能为呕吐反射的的最后共同通路，因此在不远的将来，单一药物治疗PONV有可能成为现实。
3.类固醇（Steroids）能否降低PONV的发生？
糖皮质激素（例如地塞米松、甲基强地松龙）多年以来一直作为化学治疗导致的呕吐预防手段之一，最近的meta分析表明，当单独应用糖皮质激素时，其象其它镇吐药一样有效。当合并应用镇吐药时又优于镇吐药。迄今为止，其作用机制尚不清楚。
4.抑制PONV的的非药物措施有哪些？
PONV领域内最近的有意义的工作包括非药物治疗技术的使用，特别是针灸和指压疗法的使用。Dundee等发现通过对位于手腕前部的P6穴位的人工刺激可以明显降低PONV的发生率 。当给于该点低频电刺激时可以得到同样的结果，但是该点并非均一有效。在接受斜视手术的患儿，指压治疗不能抑制PONV的发生，但是有其它压力点治疗有效的报道。
最近关于非药物治疗技术的meta分析评估了针灸、电针疗法、经皮电刺激神经疗法以及穴位刺激和指压疗法，其结论为：这些技术与通常使用的镇吐药的效能大致相当。当对这些技术的副作用的评价是良好的时候，关于预防和治疗PONV的这些技术可以进行更深层次的控制研究，以寻求其稳定的治疗方法。

[每周一问]No.7-Treatment of PONV英文参考答案
Is the prophylactic use of antiemetics justified?
Most investigators agree that the routine administration of antiemetics is not justified, as most patients will not experience PONV and should it occur, most will have mild symptoms. Scuderi et al. (1) even argue that although the incidence of PONV is reduced, little evidence exists to suggest that time of discharge, unanticipated admissions, patient satisfaction, and time to return to normal activity are improved. Moreover, many of the commonly administered antiemetics can have significant side effects and some of the new agents, particularly the antihistamines and antiserotonergics are extremely expensive.

Does effective single agent therapy exist?
Due to the number and variety of stimuli and receptors involved in causing PONV, no single agent has been demonstrated to fully prevent or treat PONV. Thus, the use of multiple agents with different mechanisms has been suggested as the most effective way to currently treat PONV. This being said, recent evidence has suggested that the NK1 receptor may represent the final common pathway of the emetic reflex (2, 3), and hopefully, in the near future, very effective single agents may be available.

Can steroids reduce the incidence of PONV?
Used for many years for the prevention of chemotherapy induced vomiting, glucocorticoids (e.g. dexamethasone, methylprednisolone) in a recent meta-analysis have been noted to be as effective as other antiemetics when used alone, and superior to antiemetics when used in combination with them (4). Currently, the mechanism of their activity remains undetermined.

What are some nonpharmacologic therapies to prevent PONV?
Some of the most recent, interesting work in the area of PONV involves the use of nonpharmacologic techniques, especially with acupuncture and acupressure. Dundee et al. (5) found that manual stimulation of the acupuncture point P6, which is located on the anterior aspect of wrist, produced a significant decrease in the incidence of PONV. Similar results were obtained when low frequency electrical stimulation to this point was applied . Yet this point has not been uniformly effective; in children undergoing strabismus surgery, acupressure failed to prevent POV (7). Other pressure points have been utilized with some success as well .
A recent meta-analysis of nonpharmacologic techniques evaluating acupuncture, electroacupuncture, transcutaneous electrical nerve stimulation, acupoint stimulation and acupressure, concluded that these techniques were approximately equivalent to commonly used antiemetic medications (9). As the side effect profiles of these modalities are favorable, further controlled trials may support a permanent role for these modalities in PONV prevention and treatment.
Question Author: Lawrence Tsen, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School
References:
1.  Scuderi PE, James RL, Harris L, et al. Antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic treatment. Anesthesiology 1999;90:360-71.
2.  Tattersall FD, Rycroft W, Francis B, et al. Tachykinin NK1 receptor antagonists act centrally to inhibit emesis induced by the chemotherapeutic agent cisplatin in ferrets. Neuropharmacology 1996;35:1121-9.
3.  Diemunsch P, Schoeffler P, Bryssine B, et al. Antiemetic activity of the NK1 receptor antagonist GR205171 in the treatment of established postoperative nausea and vomiting after major gynaecological surgery. Br J Anaesth 1999;82(2):274-6.
4.  Eberhart LH, Morin AM, Georgieff M. [Dexamethasone for prophylaxis of postoperative nausea and vomiting. A meta-analysis of randomized controlled studies]. Anaesthesist 2000;49:713-20.
5.  Dundee JW, Chestnut WN, Ghaly RG, et al. Traditional Chinese acupuncture: a potentially useful antiemetic? BMJ 1986;293:583-4.
6.  Ghaly RG, Fitzpatrick KTJ, Dundee JW. Antiemetic studies with traditional Chinese acupuncture: a comparison of manual needling with electrical stimulation and commonly used antiemetics. Anaesthesia 1987;42:1108-10.
7.  Lewis IH, Pryn SJ, Reynolds PI, et al. Effect of P6 acupressure on postoperative vomiting in children undergoing outpatient strabismus correction. Br J Anaesth 1991;67:73-8.
8.  Schlager A, Boehler M, Puhringer F. Korean hand acupressure reduces postoperative vomiting in children after strabismus surgery. Br J Anaesth. 2000;85(2):267-70.
9.  Lee A, Done ML. The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg 1999;88:1362-9.
Site Editor: Stephen B. Corn, M.D. and B. Scott Segal, M.D.
Department of Anesthesia, Harvard Medical School

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