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How much does pharmacologic prophylaxis reduce postoperative vomiting in children? Calculation of prophylaxis
Edgard Engelman1, Jean-Corentin Salengros, Luc Barvais
1Department of Anesthesiology, Erasme Hospital, 808 Route de Lennik, 1070 Brussels, Belgium. eengelma@ulb.ac.be
Insights
New guidelines for pediatric postoperative nausea and vomiting management show combination therapies, including 5-hydroxytryptamine receptor antagonists and dexamethasone, offer an 80% risk reduction for vomiting.
Area of Science:
- Pharmacology and Therapeutics
- Pediatric Anesthesiology
- Evidence-Based Medicine
Background:
- Guidelines for managing postoperative nausea and vomiting (PONV) in children require updated effect size calculations for recommended treatments.
- A new pediatric risk scale is available to aid in implementing these guidelines.
- This study focuses on evaluating the efficacy of various antiemetic treatments in the pediatric population.
Purpose of the Study:
- To calculate the effect size for treatments recommended in the new pediatric PONV guidelines.
- To assess the relative risk reduction for postoperative vomiting associated with different antiemetic therapies.
- To provide data that can be applied using a new pediatric risk scale.
Main Methods:
- A Bayesian analysis was performed on six single-drug and five combination antiemetic therapies.
- Treatments were analyzed sequentially based on publication dates, updating probabilities with each new study.
- Final odds ratios were converted to relative risks with credibility intervals to estimate vomiting incidence.
Main Results:
- 5-hydroxytryptamine receptor antagonists and dexamethasone demonstrated a pessimistic relative risk reduction of 50-60%.
- Droperidol showed a lower risk reduction of approximately 40%.
- Combination therapies of 5-hydroxytryptamine receptor antagonists and dexamethasone achieved the highest risk reduction, around 80%.
Conclusions:
- Combination antiemetic therapy, specifically involving 5-hydroxytryptamine receptor antagonists and dexamethasone, offers substantial risk reduction for pediatric PONV.
- The study provides expected incidence and relative risks for various treatments across different pediatric risk categories.
- These findings support the implementation of updated PONV management guidelines using a risk-stratified approach.
Background:
The authors calculated the effect size for treatments recommended for the pediatric population in the new Guidelines for the Management of Postoperative Nausea and Vomiting that should be implemented with the help of a new risk scale developed for children.
Methods:
Six single-drug therapies and five combination treatments were subjected to a Bayesian analysis, with respect to the outcome reported, in a sequence that parallels their dates of publication. Based on the Bayes theorem, a posterior probability was calculated after inclusion of the data from the successive studies, to update a prior probability existing before inclusion of that study. The posterior for the preceding group of trials served as the prior for the subsequent trial. The final odds ratio with its 95% credibility interval compared with placebo is considered as the results for that treatment, and was transformed into a relative risk whose 95% credibility interval allows the calculation of a most pessimistic and a most optimistic incidence of postoperative vomiting.
Results:
The most pessimistic expectations with the 5-hydroxytryptamine receptor antagonists and dexamethasone result in a 50-60% relative risk reduction. The results with droperidol offer a decrease of only approximately 40%. With the combinations of a 5-hydroxytryptamine receptor antagonist and dexamethasone, a relative risk reduction of approximately 80% is expected.
Conclusions:
The authors' tables list the expected incidence of postoperative vomiting with each treatment for each risk category, and the expected relative risks that can be used with baseline risk values from any source.
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