Duke University Medical Center, Box 3094, Durham, NC 27710, USA.
Anesth Analg. 2011 Apr;112(4):813-8. doi: 10.1213/ANE.0b013e3181ff47e2. Epub 2010 Nov 16.
Postoperative nausea and vomiting (PONV) occur commonly after craniotomy. In patients receiving prophylaxis with ondansetron and dexamethasone, vomiting occurred in 45% of patients at 48 hours. In addition to causing patient discomfort, the physical act of vomiting may increase intracranial pressure or cerebral intravascular pressure, jeopardizing hemostasis and cerebral perfusion. Aprepitant is a neurokin-1 receptor antagonist with a long duration of action and no sedative side effect. In a large multicenter study in patients undergoing abdominal surgery, aprepitant was significantly more effective than was ondansetron in preventing vomiting at 24 and 48 hours postoperatively. We hypothesized that the combination of aprepitant with dexamethasone will decrease the incidence of postoperative vomiting when compared with the combination of ondansetron and dexamethasone in patients undergoing craniotomy under general anesthesia.
Patients scheduled to undergo craniotomy under general anesthesia were enrolled in this prospective, double-blind, randomized study. Patients were randomized to receive oral aprepitant 40 mg (or matching placebo) 1 to 3 hours before induction of anesthesia or ondansetron 4 mg IV (or placebo) within 30 minutes of the end of surgery. All patients received dexamethasone 10 mg after induction of anesthesia. The anesthetic technique was standardized. Data were collected at regular intervals by blinded personnel for 48 hours after surgery. Statistical analysis was performed using Wilcoxon's ranked sum test and χ(2) test. P < 0.05 was considered statistically significant.
One hundred four patients completed the study. The cumulative incidence of vomiting at 48 hours was 16% in the aprepitant group and 38% in the ondansetron group (P = 0.0149). The incidence of vomiting was also decreased in the aprepitant group at 2 hours (6% vs. 21%, P = 0.0419) and 24 hours (14% vs. 36%, P = 0.0124). From 0 to 48 hours, there was no difference between the aprepitant and ondansetron groups in the incidence of nausea (69% vs. 60%), nausea scores, need for rescue antiemetics (65% vs. 60%), complete response (no PONV and no rescue, 22% vs. 36%), or patient satisfaction with the management of PONV.
The combination of aprepitant and dexamethasone was more effective than was the combination of ondansetron and dexamethasone for prophylaxis against postoperative vomiting in adult patients undergoing craniotomy under general anesthesia. However, there was no difference between the groups in the incidence or severity of nausea, need for rescue antiemetics, or in complete response between the groups.
颅手术后常发生术后恶心呕吐（PONV）。在接受昂丹司琼和地塞米松预防的患者中，48 小时时有 45%的患者发生呕吐。除了引起患者不适外，呕吐的物理动作可能会增加颅内压或脑血管内压，危及止血和脑灌注。阿瑞匹坦是一种具有长效作用且无镇静副作用的神经激肽-1 受体拮抗剂。在一项针对接受腹部手术的患者的大型多中心研究中，与昂丹司琼相比，阿瑞匹坦在术后 24 和 48 小时预防呕吐方面更有效。我们假设与昂丹司琼和地塞米松联合使用相比，阿瑞匹坦联合地塞米松可降低全麻下接受颅手术的患者术后呕吐的发生率。
本前瞻性、双盲、随机研究纳入了计划接受全麻下颅手术的患者。患者被随机分配接受口服阿瑞匹坦 40 毫克（或匹配安慰剂），在麻醉诱导前 1 至 3 小时，或在手术结束后 30 分钟内接受静脉注射昂丹司琼 4 毫克（或安慰剂）。所有患者在麻醉诱导后均接受地塞米松 10 毫克。采用标准化的麻醉技术。通过盲法人员在术后 48 小时内定期收集数据。使用 Wilcoxon 秩和检验和 χ(2)检验进行统计分析。P<0.05 被认为具有统计学意义。
104 例患者完成了研究。48 小时时呕吐的累积发生率在阿瑞匹坦组为 16%，在昂丹司琼组为 38%（P=0.0149）。阿瑞匹坦组在 2 小时（6%比 21%，P=0.0419）和 24 小时（14%比 36%，P=0.0124）时呕吐的发生率也降低了。0 至 48 小时时，阿瑞匹坦组和昂丹司琼组的恶心发生率（69%比 60%）、恶心评分、需要解救性止吐药（65%比 60%）、完全缓解（无 PONV 和无解救，22%比 36%）或患者对 PONV 管理的满意度均无差异。
在全麻下接受颅手术的成年患者中，阿瑞匹坦联合地塞米松预防术后呕吐的效果优于昂丹司琼联合地塞米松。然而，两组间恶心的发生率或严重程度、需要解救性止吐药或完全缓解方面无差异。
