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Practice Guidelines for the Management of Postoperative Nausea and Vomiting: Past, Present, and Future

2007; Lippincott Williams & Wilkins; Volume: 105; Issue: 6 Linguagem: Inglês

10.1213/01.ane.0000295854.53423.8a

1526-7598

Peter S. A. Glass, Paul F. White,

Cardiac, Anesthesia and Surgical Outcomes

Evidence-based practice guidelines have the potential to provide valuable information to clinicians and their patients. Not only do they provide guidance in everyday practice, but they establish the “standard of care” for the specialty. Practice guidelines must be developed by experts in the field using the best available data obtained from a comprehensive review of the peer-reviewed medical literature. Consensus guidelines must then be thoroughly vetted through a respected professional organization that has an interest in providing this information to their membership to improve patient care (1). To date, the development of practice guidelines related to anesthesia has largely been the purview of the American Society of Anesthesiologists (ASA). Over the years, smaller societies that represent subspecialty interests in anesthesia have evolved. Some of these organizations are associated with Anesthesia & Analgesia, evidenced by their logos on the Journal’s masthead. These organizations, like the ASA, can bring value to their membership by developing clinical practice guidelines. The Society of Ambulatory Anesthesia (SAMBA) is one such affiliate. SAMBA does not have the financial resources of the ASA at its disposal. Without sponsorship, SAMBA would not be able to finance the development of guidelines for a topic of great interest to its members: postoperative nausea and vomiting (PONV). In 2005, a proposal was brought to the SAMBA Board of Directors whereby pharmaceutical companies with vested interests in drugs used to manage PONV would sponsor a program to create practice guidelines. These companies provided educational grants to SAMBA that funded the development of PONV guidelines published in this issue of the Journal (2). To preclude bias, the sponsors had no role in the selection of the review committee, or in development of the guidelines. Indeed, the sponsors’ first look at the guidelines will be when they read the manuscript in this issue of the Journal. We welcome readers assessment of whether this is an acceptable manner for small societies to develop consensus guidelines. The guidelines were developed by experts in the field of PONV. Many of the panel members were not members of SAMBA, but rather represented a broad range of clinical experience in dealing with this common postoperative side effect. The guidelines are somewhat vague about how the members were chosen. However, in follow-up discussions with the lead author (T. J. Gan, personal communication, September 14, 2007), the criteria included the following: the members were either coauthors of the first consensus guidelines, or were added at the request of interested societies (Valarie Hooper, recommended by the American Society of PeriAnesthesia Nursing [who have developed their own guidelines1], and Craig Vander Kolk, recommended by the American Society for Plastic Surgeons), were selected to increase the geographic diversity (Peter Kranke from Germany, Paul Myles from Australia, Ashraf Habib from Egypt [although currently practicing at Duke]), or to provide statistical expertise (Greg Samsa, a statistician with the Duke Clinical Research Institute). The panel members each received an honorarium of $2500 for their efforts, as well as reimbursement for their expenses to travel to the consensus development meeting. To vet these guidelines, an initial draft was presented in a public SAMBA forum to elicit comments from their membership. In addition, draft guidelines were posted on the SAMBA Web site, and SAMBA members were invited to comment. Once this process was completed, the SAMBA Board of Directors voted to endorse the final guidelines. All guidelines eventually become out of date (3). In rapidly changing fields, this may happen by the time publication. Following the submission of these guidelines for publication, ondansetron has become available as a generic drug and its price has plummeted. With ondansetron so inexpensive, is it wise to reserve multimodal antiemetic therapy for patients with well-known risk factors, as recommended by the guidelines? Given the high efficacy, low cost, and excellent safety profiles of the most commonly used antiemetic drugs (e.g., droperidol, dexamethasone, and ondansetron), in our view these drugs should be routinely administered for antiemetic prophylaxis of all patients receiving general anesthesia irrespective of their risk classification (4). Obviously, expensive new antiemetic drugs (e.g, aprepitant, an NK-1 antagonist) should be reserved for use in situations where they have been demonstrated to offer advantages over less expensive regimens in well-controlled clinical trials. PONV is far better studied than the post-discharge nausea and vomiting (PDNV). There is a pressing need for additional clinical studies evaluating the impact of antiemetic therapies on PDNV. Oral opioid-containing analgesics for postoperative pain management are a major factor contributing to the occurrence of nausea and vomiting following discharge from a hospital or ambulatory surgery facility. It is possible that longer acting antiemetics (e.g., transdermal scopolamine, palonosetron) may offer significant advantages over the commonly used antiemetics. In a recently published comparative study (5), transdermal scopolamine was found to be effective even when administered in the immediate preoperative period. In today’s era of modern technology, is there a better way to provide effective practice guidelines in a timely manner and at a reasonable cost? Clearly the process developed by the ASA, and emulated by our affiliate societies, is somewhat archaic and poorly responsive to “the clinicians working in the trenches.” Modern medicine has rapidly accepted technology to enhance diagnosis and therapy, but has been slow to use it for process improvement (e.g., the relatively slow growth of electronic records). Wikipedia is a model that may well work in the medical community to rapidly provide true consensus guidelines. Wikipedia is “a multilingual, web-based, free content encyclopedia project”.2 Wikipedia allows experts and nonexperts to develop collaboratively a living document that expresses the opinion of the majority and is able to change rapidly as evidence becomes available to change practice. Information is continuously corrected by the users so that in the end the “consensus” opinion prevails. Using a single entry source for the entire anesthesia community to initiate and develop guidelines with true consensus is a realistic goal based on the model created by Wikipedia. The challenge is to create the site, adopt rules similar to those created by Wikipedia that would apply to the health care community, and then have anesthesia providers actively engaged in the process. We could create such guidelines with the existing Wikipedia Web site. Perhaps this editorial will inspire that effort.