Secondary Logo

Journal Logo

Combination of 5-HT3 Antagonist and Dexamethasone Is Superior to 5-HT3 Antagonist Alone for PONV Prophylaxis After Laparoscopic Surgeries: A Meta-analysis

Som, Anirban MD; Bhattacharjee, Sulagna MD, DNB; Maitra, Souvik MD, DNB; Arora, Mahesh K MD; Baidya, Dalim Kumar MD

doi: 10.1213/ANE.0000000000001617
Ambulatory Anesthesiology and Perioperative Management
Free
SDC

INTRODUCTION: 5-Hydroxytryptamine type 3 (5-HT3) receptor antagonists are the most commonly used drugs for postoperative nausea vomiting (PONV) prophylaxis. Dexamethasone is another antiemetic with proven efficacy in reducing PONV. The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the combination of dexamethasone and 5-HT3 antagonist versus a 5-HT3 antagonist alone as prophylaxis of PONV in laparoscopic surgical patients.

METHODS: PubMed, PubMed Central, and CENTRAL databases were searched to identify those randomized trials that compared a 5-HT3 antagonist with the 5-HT3 antagonist and dexamethasone combination for PONV prophylaxis after laparoscopic surgeries.

RESULTS: Data from 17 RCTs that evaluated 1402 patients were included. Results from our meta-analysis show that the combination of dexamethasone and a 5-HT3 receptor antagonist is more effective in preventing PONV than the 5-HT3 antagonist alone (odds ratio 0.38, 95% confidence interval [CI] 0.27–0.54; number needed to treat = 6.6), with no statistical heterogeneity (I2 = 0) among studies. The need for rescue antiemetic is also decreased in patients receiving the combination (odds ratio 0.21, 99% CI 0.10–0.46; number needed to treat = 6), although data are insufficient to detect any significant difference in incidence of adverse effects. In addition, patients in the combination group complained of less pain after 24 hours (Weighted Mean Difference −0.67, 99% CI −1.27 to −0.08).

CONCLUSION: Combination of a 5-HT3 receptor antagonist and dexamethasone is significantly more effective than 5-HT3 antagonist alone in preventing PONV after laparoscopic surgeries, with possible improvement in postoperative analgesia.

From the Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, 110029, India.

Accepted for publication August 18, 2016.

Funding: No external fund was received.

This report is a meta-analysis. The author states that the report includes every item in the PRISMA checklist for meta-analysis clinical studies.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Dalim Kumar Baidya, MD, Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, 110029, India. Address e-mail to dalimkumarb001@yahoo.co.in.

Laparoscopic surgical procedures have the advantages of quick recovery, shorter hospital stay, and early return to regular activities, when compared with open surgical procedures. One of the most common causes of morbidity after laparoscopic surgery is postoperative nausea and vomiting (PONV) with reported incidences in the range of 40% to 80%.1 Studies have revealed multiple risk factors for PONV in laparoscopic surgery: exposure to opioids, female sex, history of previous PONV, type of surgical procedure, prolonged surgery, carbon dioxide retention, and peritoneal distension because of pneumoperitoneum.2–6 PONV may delay recovery and discharge,2 thus nullifying the primary advantages of laparoscopy; and excessive vomiting may result in dehydration and electrolyte imbalances. Therefore, it is imperative to reduce the incidence of these adverse events in the most effective manner possible.

Various classes of drugs have been studied as prophylaxis and treatment of PONV,4 including serotonin antagonists,2,3,7–9 anticholinergics,8 butyrophenones,10 benzamides,2,3 steroids,7,11,12 and antihistamines.9 5-Hydroxytryptamine type 3 (5-HT3) receptor antagonists are the most commonly used class of antiemetics in the perioperative setting. The 5-HT3 receptor antagonists block receptors in the chemoreceptor trigger zone (CTZ) as well as in the vagal nerve terminals. Dexamethasone enhances the antiemetic effect of 5-HT3 receptor antagonists, although the exact mechanism is not known.13

Because the cause of PONV is multifactorial, combinations of different classes of antiemetics are likely to be more effective than monotherapy.14,15 Several studies have compared combinations of dexamethasone with one of the 5-HT3 receptor antagonists with the latter alone in various types of gynecological, obstetric, pediatric, and general surgical procedures. A meta-analysis has reported outcomes in favor of the combination of dexamethasone with ondansetron in children undergoing strabismus surgery.16 No similar review could be found concerning patients undergoing laparoscopic procedures. Habib et al17 in 2004 found that the combination of ondansetron and dexamethasone was superior to ondansetron alone for PONV prophylaxis, but the studies included were composed of a heterogeneous surgical population. Hence, this systematic review and meta-analysis was designed to find out whether the combination of dexamethasone and 5-HT3 antagonist is superior to the latter alone as prophylaxis of PONV in laparoscopic surgical patients.

Back to Top | Article Outline

METHODS

The reporting of this systematic review and meta-analysis follows the PRISMA recommendations.18 A protocol for this systematic review and meta-analysis has not been registered.

Back to Top | Article Outline

Bibliographical Search and Analysis

Prospective, randomized-controlled trials (RCTs) that compared the prophylactic effects of the combination of dexamethasone and a 5-HT3 receptor antagonist with that of the latter alone on PONV in adult patients undergoing laparoscopic procedures were included in the meta-analysis. Only those studies that clearly documented the anesthetic techniques and the protocols of administration of the drugs under study and clearly described the definition and evaluation of nausea and vomiting were included. We did not impose any language restriction or seek unpublished data or trials.

Two authors (A.S. and S.M.) independently searched PubMed, PubMed Central, Scopus, Central Register of Clinical Trials of the Cochrane Collaboration, and Google Scholar for eligible controlled trials using the following search words: laparoscopy, laparoscopic surgery, dexamethasone, ondansetron OR granisetron OR palonosetron OR ramosetron OR dolasetron OR tropisetron OR antiserotonin, postoperative, nausea, vomiting OR PONV until July 31, 2015. The detailed search strategy in PubMed is described in the Supplemental Digital Content 1 (http://links.lww.com/AA/B523). No non-English database was searched.

Two authors (A.S. and S.B.) independently searched for the potentially eligible trials and selected the trials to be included. Any disagreement arising between these 2 authors was settled by the third author (S.M.). A flow diagram showing study selection procedure is shown in Figure 1.

Figure 1.

Figure 1.

Prospective observational studies, retrospective analysis, trials conducted in pediatric populations, case reports, case series, animal studies, and studies not reporting on any one of the predefined outcomes were excluded from the analysis. Studies were excluded if the patients were undergoing nonlaparoscopic procedures, or the drugs under study were not administered intravenously.

We collected the required data from the full text of the trials. Initially, all data were tabulated in Microsoft ExcelTM spread sheet. One author (S.M.) initially extracted data from the eligible trials, and those data were cross-checked independently by 2 other authors (A.S. and D.K.B.). Statistical analyses were done by 2 authors (S.M. and A.S.) independently and cross-checked.

The following data were collected from each of the studies: name of the first author, year of publication, incidence of nausea, vomiting, and PONV during the postoperative period at 6 and 24 hours, number of patients requiring a rescue antiemetic, pain intensity at 24 hours, and reported complications.

The quality of eligible trials was assessed using the tool of “risk of bias” according to Review Manager, version 5.2.3 software (RevMan; Cochrane Collaboration, Oxford, UK). Random sequence generation, allocation concealment, blinding, incomplete data, and selective reporting were assessed independently by 2 authors (S.M. and D.K.B.) based on the method of the trials, and each was graded “yes,” “no,” or “unclear,” which reflected a high risk of bias, low risk of bias, and uncertain bias, respectively. Publication bias was assessed by funnel plot and Egger regression test, which is furnished in the Supplemental Digital Content 2 (http://links.lww.com/AA/B524).

Back to Top | Article Outline

Statistical Analysis

Primary outcome of this meta-analysis was the incidence of PONV during the initial 24 postoperative hours. The secondary outcomes were incidence of nausea and vomiting during the postoperative period at 6 and 24 hours, incidence of PONV during the initial 6 hours, number of patients requiring a rescue antiemetic, pain intensity at 24 hours, and reported complications. For continuous outcomes, means and SD values were extracted for both groups, a mean difference was computed at the study level, and a weighted mean difference was computed to pool the results across all studies. If the values were reported as median and an interquartile range or total range of values, the mean value was estimated using the median and the low and high end of the range for samples smaller than 25; for samples greater than 25, the median itself was used. The SD was estimated from the median and the low and high end of the range for samples smaller than 15, as range/4 for samples from 15 to 70, and as range/6 for samples more than 70. If only an interquartile range was available, SD was estimated as interquartile range/1.35.19 For binary outcomes, we calculated the following: (1) the odds ratio (OR) for each trial; (2) the pooled OR using the Mantel-Haenszel method; (3) the number needed to treat (NNT) where a statistical significance was found, that is, the number of patients who must be treated for 1 patient to benefit from the intervention.

Primary outcome was calculated with 95% confidence interval (95% CI), and secondary outcomes with 99% confidence interval (99% CI). The I2 statistic was used to analyze the heterogeneity of trials. As possibility of heterogeneity is high because of different anesthetic techniques used, inverse variance random-effects model was used for analysis even when I2 < 30%. A priori, it was decided that the primary outcome (incidence of PONV during the initial 24 postoperative hours) will be subanalyzed according to specific 5-HT3 antagonists studied, if possible. Pooled analysis was done in RevMan software (Review Manager [computer program]; version 5.3, 2014, The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen). Publication bias was tested by visual inspection of funnel plot, and Egger regression test was performed in Comprehensive Meta-analysis software (version 2.2.034, 2006, Biostat, Englewood, NJ).

Back to Top | Article Outline

RESULTS

Study Selection

Table 1.

Table 1.

The review methodology has been depicted in Figure 1 as per PRISMA guidelines.18 Finally, 17 randomized controlled trials7,11,12,14,20–32 met our inclusion criteria and a total of 1402 adult patients (702 patients in combination group and 700 patients in 5-HT3 receptor antagonist alone group) were included in the meta-analysis and have been summarized in Table 1. There was no disagreement among the authors regarding inclusion of studies.

Back to Top | Article Outline

Risk of Bias Within Studies

Figure 2.

Figure 2.

All the included studies were randomized. Summary of risk of bias for individual studies is shown in Figure 2.

Back to Top | Article Outline

Characteristics of Individual Studies

Summary of findings from individual studies is provided in Table 1. Nine RCTs11,12,14,21,23,26,28,30,32 studied ondansetron with dexamethasone, whereas granisetron22,29 and ramosetron20,24 were studied by 2 RCTs each. Three RCTs25,27,31 studied palonosetron, and 1 RCT7 studied dolasetron. All studies evaluated an 8-mg dose of dexamethasone, except 3: two7,30 used 4 mg and one21 used 10 mg.

Eleven trials were conducted on patients undergoing laparoscopic cholecystectomy,7,11,12,20,24–26,29–32 2 on laparoscopic bariatric surgery,22,23 1 each on diagnostic laparoscopy,14 laparoscopic tubal ligation,28 laparoscopy-assisted vaginal hysterectomy,21 and outpatient laparoscopic surgery.27

The follow-up period was 6 hours for 2 studies,23,24 24 hours for 10 studies,7,11,12,14,22,24,26,28–30 48 hours for another 4 RCTs,20,21,25,31 and 72 hours for 1 RCT.27

Back to Top | Article Outline

PONV at 24 Hours

Figure 3.

Figure 3.

Eleven trials7,11,20,22,24–26,28–31 reported the incidence of PONV together up to 24 hours; and the difference was statistically significant in favor of the combination group (OR 0.38, 95% CI 0.27–0.54; I2=0%; NNT = 6.6; n = 951; Figure 3). When the composite end point of PONV is considered, results for specific 5-HT3 antagonists were statistically significant for ondansetron (OR 0.29, 95% CI 0.16–0.53; I2 = 0%; NNT = 5.4; n = 335; 4 RCTs11,26,28,30) and palonosetron (OR 0.22, 95% CI 0.08–0.64; NNT = 6; n = 144; 2 RCTs25,31). Granisetron (OR 0.36, 95% CI 0.12–1.06; I2 = 0%; n = 180; 2 RCTs22,29) and ramosetron (OR 0.52, 95% CI 0.14–1.89; I2 = 61%; n = 152; 2 RCTs20,24) did not show statistically significant results, but the confidence intervals were wide suggesting that our data are insufficient to reach a conclusion regarding this outcome. Only 1 trial7 used dolasetron, results of which favored the combination. Visual inspection of funnel plot revealed asymmetry; however, Egger regression test did not suggest any publication bias (P = .16). Incidences of nausea and vomiting separately up to 24 hours postoperatively were reported by 9 RCTs7,11,14,20,22,25,26,29,31: their pooled analysis showed statistically significant improvement with the combination (nausea: OR 0.31, 99% CI 0.16–0.59; I2 = 0%; NNT = 8.5; n = 742; vomiting: OR 0.35, 99% CI 0.16–0.76; I2 = 0%; NNT = 11.3; n = 742). (Supplemental Digital Content 2, http://links.lww.com/AA/B524.)

Back to Top | Article Outline

PONV at 6 Hours

Figure 4.

Figure 4.

Five studies11,12,25,26,32 reported incidences of nausea and vomiting separately up to 6 hours in the postoperative period; and pooled analysis shows statistically significant benefit when dexamethasone has been combined with 5-HT3 antagonist rather than the latter alone in terms of prevention of nausea (OR 0.26, 99% CI 0.11–0.66; I2 = 0%; NNT = 8.8; n = 405); however, the pooled data were inconclusive with respect to prevention of vomiting, with a wide confidence interval (OR 0.37, 99% CI 0.12–1.15; I2 = 0%; n = 405). Pooled analysis from 6 trials,11,23,25–27,32 which reported incidence of PONV combined together, did not show statistically significant difference (OR 0.43, 99% CI 0.17–1.09; I2 = 33%; n = 475; Figure 4). Among these 6 trials, 4 studied ondansetron and the other 2 studied palonosetron. (Supplemental Digital Content 2, http://links.lww.com/AA/B524.)

Back to Top | Article Outline

Requirement for a Rescue Antiemetic

Pooled analysis from 6 RCTs11,20,26,29–31 showed the combination was more effective at reducing the requirement for a rescue antiemetic (OR 0.21, 99% CI 0.10–0.46; I2 = 0%; NNT = 6; n = 531), which was statistically significant. (Supplemental Digital Content 2, http://links.lww.com/AA/B524.)

Back to Top | Article Outline

Pain Intensity at 24 Hours

Pain score (reported in visual analog scale, 0–10 in 4 RCTs and in numerical rating scale, 0–100 in 1 RCT,20 which was converted to values in a 0–10 scale) documented at 24 hours, as reported in 5 RCTs,11,20,21,26,31 was lower in the combination group (weighted mean difference −0.67, 99% CI −1.27 to −0.08; I2 = 76%; n = 361) and the difference was statistically significant. (Supplemental Digital Content 2, http://links.lww.com/AA/B524.)

Back to Top | Article Outline

Adverse Effects

Common drug-related adverse effects that have been reported in the included RCTs are headache, dizziness, fatigue, diarrhea, transient chest pain, pruritus, and heartburn. Only headache and dizziness were reported in a sufficient number of studies so as to allow pooling of data. Their incidences (headache: OR 0.83, 99% CI 0.41 to 1.69; I2 = 0%; n = 762; 9 RCTs11,12,20,23,24,26,29–31 and dizziness: OR 1.10, 99% CI 0.33 to 3.71; I2 = 0%; n = 587; 7 RCTs11,20,23,24,26,29,30) showed no statistically significant difference between the groups, although confidence intervals are wide, suggesting insufficient data. (Supplemental Digital Content 2, http://links.lww.com/AA/B524.)

Back to Top | Article Outline

DISCUSSION

One of the most common events that delays recovery after laparoscopic surgeries is postoperative nausea and vomiting. Results from our meta-analysis showed that the combination of dexamethasone and a 5-HT3 receptor antagonist, when administered prophylactically, is more effective in preventing PONV than the 5-HT3 antagonist alone, with very little heterogeneity among studies. The need for rescue antiemetic is also decreased in patients receiving the combination, although data are insufficient to detect any significant difference in the incidence of adverse effects. In addition, patients in the combination group reported less pain after 24 hours. However, the benefit is statistically significant only when dexamethasone is used along with ondansetron or palonosetron; definitive conclusions cannot be drawn for granisetron, ramosetron, or dolasetron because the CIs are wide in the absence of adequate number of RCTs.

Numerous RCTs have studied the effects of prophylactic 5-HT3 antagonists on PONV in laparoscopic surgeries and beneficial effect has been confirmed by meta-analysis.33 No specific 5-HT3 antagonist has been found to be better than another until now.34 The effect of dexamethasone has also been studied, and a meta-analysis by Karanicolas et al35 showed that dexamethasone significantly decreases PONV compared with placebo in laparoscopic cholecystectomy with a relative risk (RR) of 0.55. This study also reported the effect of dexamethasone in potentially decreasing postoperative pain.

Shen et al16 compared the effects of ondansetron, dexamethasone, and their combination in pediatric strabismus surgery in a meta-analysis and reported that both drugs were better than placebo in preventing PONV. This meta-analysis also compared ondansetron versus ondansetron and dexamethasone combination from 2 studies and observed that the combination was significantly better than ondansetron alone with a RR of 3.11.

In a meta-analysis by Habib et al,17 the combination of a 5-HT3 antagonist and dexamethasone was found to be better than the 5-HT3 antagonist alone in preventing overall nausea (NNT = 8) and vomiting (NNT = 7). This review included both adult and pediatric populations, as well as different surgical techniques.

Our study corroborates these findings, including a certain analgesic efficacy of dexamethasone. 5-HT3 receptor antagonists exert their effect on 5-HT3 receptors present both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone of the area postrema.36,37 In contrast, dexamethasone has a central mechanism of action through an activation of the glucocorticoid receptors in the bilateral nuclei tractus solitarii in the medulla38 as well as a noncompetitive direct inhibitory effect on 5-HT3 receptors that is additive to the effects of 5-HT3 antagonists.39 Although 5-HT3 antagonists are quite effective against vomiting, dexamethasone also decreases the incidence of vomiting, but seems to have a more specific effect against nausea.40 This may explain why the combination produces an additive effect.11

The included studies were heterogeneous in many aspects, including different narcotics having been used in different doses and at different timings along with different types of surgeries and induction techniques. But overall, the statistical heterogeneity for the primary as well as most of the secondary outcome measures was minimal.

Finally, although the funnel plot is asymmetric, Egger regression test did not suggest any publication bias (P = .16). So the asymmetry is unlikely to represent publication bias (Figure 5).

Figure 5.

Figure 5.

There are a few limitations to this study. First, most of the studies did not report the detailed method of allocation concealment, and some of the studies did not mention methods of blinding. Second, some of the RCTs were conducted on relatively small sample sizes. Third, all RCTs did not report the primary or secondary outcomes, thus limiting the statistical power of this study. Fourth, there were an inadequate number of RCTs evaluating specific 5-HT3 antagonists, which precluded any meaningful conclusions from the subgroup analyses. Fifth, some of the RCTs used propofol for induction, whereas others used thiopental. Sixth, although most of the RCTs recorded 5-HT3 antagonist-related common adverse effects, none of them reported steroid related side-effects, for example, wound healing/infection, glycemic control, presence of mania, etc. Since the safety profile of perioperative dexamethasone is still inconclusive,2 this issue should be addressed in future RCTs. Another limitation is that pooled analysis of postoperative analgesic consumption could not be done, because the studies used different rescue analgesics.

Back to Top | Article Outline

CONCLUSION

In conclusion, combination of a 5-HT3 receptor antagonist and dexamethasone is significantly more effective than a 5-HT3 antagonist alone in preventing PONV after laparoscopic surgeries, with possible improvement in postoperative analgesia.

Back to Top | Article Outline

DISCLOSURES

Name: Anirban Som, MD.

Contribution: This author helped design the study, analyze the data, and write the manuscript.

Name: Sulagna Bhattacharjee, MD, DNB.

Contribution: This author helped design the study and analyze the data.

Name: Souvik Maitra, MD, DNB.

Contribution: This author helped design the study and write the manuscript.

Name: Mahesh K Arora, MD.

Contribution: This author helped conduct the study and write the manuscript.

Name: Dalim Kumar Baidya, MD.

Contribution: This author helped design the study and conduct the study.

This manuscript was handled by: Tong J. Gan, MD.

Back to Top | Article Outline

REFERENCES

1. Gupta P, Khanna J, Mitramustafi AK, Bhartia VKRole of pre-operative dexamethasone as prophylaxis for postoperative nausea and vomiting in laparoscopic surgery.J Minim Access Surg200621215
2. Apfel CC, Korttila K, Abdalla M, et al.IMPACT InvestigatorsA factorial trial of six interventions for the prevention of postoperative nausea and vomiting.N Engl J Med200435024412451
3. Argiriadou H, Papaziogas B, Pavlidis T, et al.Tropisetron vs ondansetron for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: a randomized double-blind, placebo-controlled study.Surg Endosc20021610871090
4. Gan TJ, Diemunsch P, Habib AS, et al.Society for Ambulatory AnesthesiaConsensus guidelines for the management of postoperative nausea and vomiting.Anesth Analg201411885113
5. Leksowski K, Peryga P, Szyca ROndansetron, metoclopramid, dexamethason, and their combinations compared for the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a prospective randomized study.Surg Endosc200620878882
6. Wattwil M, Thörn SE, Lövqvist A, Wattwil L, Gupta A, Liljegren GDexamethasone is as effective as ondansetron for the prevention of postoperative nausea and vomiting following breast surgery.Acta Anaesthesiol Scand200347823827
7. Coloma M, White PF, Markowitz SD, et al.Dexamethasone in combination with dolasetron for prophylaxis in the ambulatory setting: effect on outcome after laparoscopic cholecystectomy.Anesthesiology20029613461350
8. Gan TJ, Sinha AC, Kovac AL, et al.TDS Study GroupA randomized, double-blind, multicenter trial comparing transdermal scopolamine plus ondansetron to ondansetron alone for the prevention of postoperative nausea and vomiting in the outpatient setting.Anesth Analg200910814981504
9. Kothari SN, Boyd WC, Bottcher ML, Lambert PJAntiemetic efficacy of prophylactic dimenhydrinate (Dramamine) vs ondansetron (Zofran): a randomized, prospective trial in patients undergoing laparoscopic cholecystectomy.Surg Endosc200014926929
10. Glaser C, Sitzwohl C, Wallner T, Lerche A, Marhofer P, Schindler IDixyrazine for the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy.Acta Anaesthesiol Scand20044812871291
11. Elhakim M, Nafie M, Mahmoud K, Atef ADexamethasone 8 mg in combination with ondansetron 4 mg appears to be the optimal dose for the prevention of nausea and vomiting after laparoscopic cholecystectomy.Can J Anesth200249922926
12. Murphy GS, Szokol JW, Greenberg SB, et al.Preoperative dexamethasone enhances quality of recovery after laparoscopic cholecystectomy: effect on in-hospital and postdischarge recovery outcomes.Anesthesiology2011114882890
13. Steely RL, Collins DR Jr., Cohen BE, Bass KPostoperative nausea and vomiting in the plastic surgery patient.Aesthetic Plast Surg2004282932
14. Rajeeva V, Bhardwaj N, Batra YK, Dhaliwal LKComparison of ondansetron with ondansetron and dexamethasone in prevention of PONV in diagnostic laparoscopy.Can J Anaesth1999464044
15. Scuderi PE, James RL, Harris L, Mims GR IIIMultimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy.Anesth Analg20009114081414
16. Shen YD, Chen CY, Wu CH, Cherng YG, Tam KWDexamethasone, ondansetron, and their combination and postoperative nausea and vomiting in children undergoing strabismus surgery: a meta-analysis of randomized controlled trials.Paediatr Anaesth201424490498
17. Habib AS, El-Moalem HE, Gan TJThe efficacy of the 5-HT3 receptor antagonists combined with droperidol for PONV prophylaxis is similar to their combination with dexamethasone. A meta-analysis of randomized controlled trials.Can J Anesth200451311319
18. Moher D, Liberati A, Tetzlaff J, Altman DGPRISMA GroupPreferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.PLoS Med20096e1000097
19. Hozo SP, Djulbegovic B, Hozo IEstimating the mean and variance from the median, range, and the size of a sample.BMC Med Res Methodol2005513
20. Ryu JH, Chang JE, Kim HR, Hwang JW, Oh AY, Do SHRamosetron vs. ramosetron plus dexamethasone for the prevention of postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy: prospective, randomized, and double-blind study.Int J Surg201311183187
21. Nam M, Yoon HEffect of ondansetron combined with dexamethasone on postoperative nausea & vomiting and pain of patients with laparoscopic hysterectomy.J Korean Acad Nurs2009394452
22. Moussa AA, Oregan PJPrevention of postoperative nausea and vomiting in patients undergoing laparoscopic bariatric surgery–granisetron alone vs granisetron combined with dexamethasone/droperidol.Middle East J Anaesthesiol200719357367
23. Mendes MN, Monteiro Rde S, Martins FAProphylaxis of postoperative nausea and vomiting in morbidly obese patients undergoing laparoscopic gastroplasties: a comparative study among three methods.Rev Bras Anestesiol200959570576
24. Jo YY, Lee JW, Shim JK, Lee WK, Choi YSRamosetron, dexamethasone, and their combination for the prevention of postoperative nausea and vomiting in women undergoing laparoscopic cholecystectomy.Surg Endosc20122623062311
25. Ghosh S, Pal A, Acharya A, Biswas C, Ghosh TR, Ghosh SPalonosetron and palonosetron plus dexamethasone to prevent postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a prospective, randomized, double-blind comparative study.Anesth Essays Res20115134137
26. Gautam B, Shrestha BR, Lama P, Rai SAntiemetic prophylaxis against postoperative nausea and vomiting with ondansetron-dexamethasone combination compared to ondansetron or dexamethasone alone for patients undergoing laparoscopic cholecystectomy.Kathmandu Univ Med J (KUMJ)20086319328
27. Blitz JD, Haile M, Kline R, et al.A randomized double blind study to evaluate efficacy of palonosetron with dexamethasone versus palonosetron alone for prevention of postoperative and postdischarge nausea and vomiting in subjects undergoing laparoscopic surgeries with high emetogenic risk.Am J Ther201219324329
28. Biswas BN, Rudra A, Mandal SKComparison of ondansetron, dexamethasone, ondansetron plus dexamethasone and placebo in the prevention of nausea and vomiting after laparoscopic tubal ligation.J Indian Med Assoc2003101638, 640, 642
29. Biswas BN, Rudra AComparison of granisetron and granisetron plus dexamethasone for the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy.Acta Anaesthesiol Scand2003477983
30. Bhattarai B, Shrestha S, Singh JComparison of ondansetron and combination of ondansetron and dexamethasone as a prophylaxis for postoperative nausea and vomiting in adults undergoing elective laparoscopic surgery.J Emerg Trauma Shock20114168172
31. Bala I, Bharti N, Murugesan S, Gupta RComparison of palonosetron with palonosetron-dexamethasone combination for prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy.Minerva Anestesiol201480779784
32. Ahsan K, Abbas N, Naqvi SM, Murtaza G, Tariq SComparison of efficacy of ondansetron and dexamethasone combination and ondansetron alone in preventing postoperative nausea and vomiting after laparoscopic cholecystectomy.J Pak Med Assoc201464242246
33. Wu SJ, Xiong XZ, Cheng TY, Lin YX, Cheng NSEfficacy of ondansetron vs. metoclopramide in prophylaxis of postoperative nausea and vomiting after laparoscopic cholecystectomy: a systematic review and meta-analysis.Hepatogastroenterology20125920642074
34. Wu SJ, Xiong XZ, Lin YX, Cheng NSComparison of the efficacy of ondansetron and granisetron to prevent postoperative nausea and vomiting after laparoscopic cholecystectomy: a systematic review and meta-analysis.Surg Laparosc Endosc Percutan Tech2013237987
35. Karanicolas PJ, Smith SE, Kanbur B, Davies E, Guyatt GHThe impact of prophylactic dexamethasone on nausea and vomiting after laparoscopic cholecystectomy: a systematic review and meta-analysis.Ann Surg2008248751762
36. Ye JH, Ponnudurai R, Schaefer ROndansetron: a selective 5-HT(3) receptor antagonist and its applications in CNS-related disorders.CNS Drug Rev20017199213
37. Bodis S, Alexander E III, Kooy H, Loeffler JSThe prevention of radiosurgery-induced nausea and vomiting by ondansetron: evidence of a direct effect on the central nervous system chemoreceptor trigger zone.Surg Neurol199442249252
38. Ho CM, Ho ST, Wang JJ, Tsai SK, Chai CYDexamethasone has a central antiemetic mechanism in decerebrated cats.Anesth Analg200499734739
39. Suzuki T, Sugimoto M, Koyama H, Mashimo T, Uchida IInhibitory effect of glucocorticoids on human-cloned 5-hydroxytryptamine3A receptor expressed in xenopus oocytes.Anesthesiology2004101660665
40. Jones AL, Hill AS, Soukop M, et al.Comparison of dexamethasone and ondansetron in the prophylaxis of emesis induced by moderately emetogenic chemotherapy.Lancet1991338483487

Supplemental Digital Content

Back to Top | Article Outline
Copyright © 2016 International Anesthesia Research Society