PONV management in patients with QTc prolongation on the EKG

Abstract

Postoperative nausea and vomiting (PONV) is a commonly encountered problem in surgical practice. It delays discharge from the post-anesthesia care unit, requires additional resources to treat, and may increase the morbidity in some patients. Many effective drugs are available to treat or prevent PONV, however many of these drugs have the potential to prolong the QTc on the electrocardiogram (EKG) and increase the risk of serious ventricular arrhythmias, in particular, torsade de pointes. The QTc prolongation may be a manifestation of a genetic mutation resulting in abnormal myocyte repolarization or it may be acquired and associated with the use of various medications, electrolyte disorders, and physiological conditions. Patients predisposed to QTc prolongation presenting for surgery constitute a challenging group, since many drugs commonly used for PONV management will put them at risk for perioperative serious arrhythmias. This is an important topic, and our mini-review is an attempt to highlight the problem, summarize the existing experience, and generate recommendations for safe management of PONV for patients, who are at increased risk of QTc prolongation and arrhythmias. Focused prospective studies will help to find definitive answers to the discussed problems and challenges and develop specific guidelines for clinical application.

Drugs in anesthesia: preventing postoperative nausea and vomiting

“…Of note, these two studies did not find clinically relevant adverse events related to amisulpride but indeed, this was not the primary end point in neither of these studies. The study by Fox et al did not find clinically relevant QT-prolongation for recommended doses of amisulpride in a small group of patients with overall low risk (ASA I-II, age 18–65 years) [16 ▪ ,18]. Unfortunately, so far head-to-head comparisons with active comparators are lacking.…”

“…One of the most relevant adverse events related to several drug classes including 5-HT 3 -antagonists and Dopamine-antagonists is QT prolongation [16 ▪ ], although the risk seems to vary widely within drug classes. For instance, QT prolongation led to a market withdrawal of dolasetrone in the USA [17].…”

Neurokinin‐1 receptor antagonists for the prevention of postoperative nausea and vomiting

“…NK1RAs have generally been regarded as having a lower risk of QT prolongation than most 5-HT3 and D2 antagonists. 66,67 In a randomized, double-blind study, QT prolongation was not observed among healthy volunteers who received a single 200-mg dose of fosaprepitant. 18,68 Furthermore, NK1RAs, unlike some D2 antagonists (e.g., droperidol and haloperidol), 67 do not cause sedation, which can prolong patient recovery time.…”

“…Clinical studies have demonstrated prophylaxis efficacy lasting 48 h after surgery with aprepitant, 35,36,38,42,45,54 casopitant, 56 fosaprepitant, [59][60][61] and rolapitant, 58 which is longer than that reported with other antiemetics, with exception of transdermal scopolamine and palonosetron, which also have a have a long duration of efficacy. NK1RAs are established as well tolerated, with typically mild to moderate AEs, and devoid of certain concerns (eg, QT prolongation and sedation) versus other classes of antiemetics 18,[66][67][68] ; however, further investigation of the safety of NK1RAs is warranted, particularly among vulnerable populations (eg, children, the elderly, and patients with comorbidities). Lastly, studies investigating the pharmacoeconomic benefits of NK1RA…”

Postoperative/postdischarge nausea and vomiting: evidence-based prevention and treatment

“…No reliable clinical data exists, however, on the likelihood of this complication and many reports question the appropriateness of the conclusions regarding the dopamine antagonists for anesthetic practice [31,32]. A recent review on this topic recommends slow titration of the least effective doses to reduce the risk of cardiac arrhythmia, thus justifying administration in most patients [33]. Regarding the NK 1 antagonists, their high efficacy is still limited by the lack of safety data.…”