Superior prolonged antiemetic prophylaxis with a four-drug multimodal regimen - comparison with propofol or placebo

Background: The purpose of this study was to compare the effects of a low-dose propofol infusion with a four-drug multimodal regimen for prophylaxis of postoperative nausea and vomiting (PONV). Methods: POW was studied in two patient groups with a known high incidence. Through a stratified randomization, 60 patients undergoing breast surgery and 120 patients undergoing abdominal surgery were randomized to three groups of equal size: the propofol group (P), the multidrug group (M) and the control group (C). All patients received general anesthesia, induction with propofol and maintenance with sevoflurane. After induction, patients in the P group received a continuous infusion of propofol 1 mg/kg/h during the operation and the first 4 postoperative h. Patients in the M group received dexamethasone 4 mg and three antiemetics, ondansetron 4 mg, droperidol 1.25 mg and metoclopramide 10 mg i.v. In the control group no prophylaxis was given. Nausea and pain were evaluated by incidence and a visual analog scale (0-10 cm). All emetic episodes were noted by the staff during the first 4 h and by the patients during the next 20 h. Results: The overall incidence of PONV during the first 24 h postoperatively was significantly lower in the M group (24%) than in the P group (49%) (P < 0.01) or the C group (70%) (P < 0.001). The incidence of PONV increased significantly both in patients undergoing breast surgery and abdominal surgery after termination of propofol. The number of patients who vomited was significantly lower in the M group, both in breast surgery patients (5%) and abdominal surgery patients (3%) compared to patients in the propofol groups (breast 16% NS; abdominal 29%, P < 0.05) and in the control groups (breast 37%, P < 0.01; abdominal 29%, P < 0.01). Conclusion: The incidence of PONV is very high in patients undergoing breast and abdominal surgery. In the present study antiemetic prophylaxis with a combination of droperidol, ondansetron, metoclopramide and dexamethasone was more effective in preventing PONV, especially vomiting, than a postoperative low-dose infusion of propofol, which had a short lasting effect.