Postoperative nausea and vomiting in patients undergoing colorectal surgery within an institutional enhanced recovery after surgery protocol: comparison of two prophylactic antiemetic regimens

Abstract

Background Enhanced recovery protocols (ERP) provide optimal perioperative care for surgical patients. Postoperative nausea and vomiting (PONV) is common after colorectal surgery (CRS). We aim to compare the efficacy of aprepitant to a cost-effective alternative, perphenazine, as components of triple antiemetic prophylaxis in ERP patients. Methods Patients who underwent ERP CRS at a single institution from July 2015 to July 2017 were evaluated retrospectively. Only subjects who received aprepitant (Group 1) or perphenazine (Group 2) preoperatively for PONV prophylaxis were included. Patient characteristics, simplified Apfel PONV scores, perioperative medications, and PONV incidence were compared between the groups. PONV was defined as the need for rescue antiemetics on postoperative days (POD) 0–5. Results Five hundred ninety-seven patients underwent CRS of which 498 met the inclusion criteria. Two hundred thirty-one (46.4%) received aprepitant and 267 (53.6%) received perphenazine. The incidence of early PONV (POD 0–1) was comparable between the two groups: 44.2% in Group 1 and 44.6% in Group 2 (P = 0.926). Late PONV (POD 2–5) occurred less often in Group 1 than Group 2, respectively (35.9% vs. 45.7%, P = 0.027). After matching the groups for preoperative, procedural, and anesthesia characteristics (164 pairs), no difference in early or late PONV could be demonstrated between the groups. Conclusions The incidence of PONV remains high despite most patients receiving three prophylactic antiemetic medications. Perphenazine can be considered a cost-effective alternative to oral aprepitant for prophylaxis of PONV in patients undergoing CRS within an ERP.

Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies

“…In addition, there is limited evidence that aprepitant is effective as a third additional agent. Holder-Murray et al 72 conducted a clinical trial of 498 patients with low-to-moderate PONV risk undergoing colorectal surgeries, and found that when used in addition to ondansetron and dexamethasone prophylaxis, aprepitant did not significantly reduce the incidence of PONV or the rescue anti-emetic requirement when compared to perphenazine. Bergese et al 73 conducted a clinical trial of 95 patients with low-to-moderate PONV risk undergoing craniotomy, and found that when used in addition to dexamethasone and promethazine prophylaxis, aprepitant did not significantly reduce the incidence of PONV or the rescue anti-emetic requirement when compared to ondansetron.…”

Oral Perphenazine 8 mg: A Low-Cost, Efficacious Antiemetic Option

“…Additionally, we evaluated the efficacy of single-dose OP8 to a single 40 mg dose of aprepitant given preoperatively in colorectal surgery patients at our academic center within an enhanced recovery protocol, which was designed to mitigate opioid utilization, reduce PONV, and optimize patient recovery. 7 In this retrospective study, no differences were noted in antiemetic requirement on postoperative days 0 and 1 between patients receiving OP8 versus aprepitant. In addition, when patients were matched for preoperative, procedural, and anesthesia characteristics, no differences were noted in late PONV between patients receiving OP8 versus aprepitant.…”

2. Adding perphenazine to increase effectiveness of standard glioblastoma chemoirradiation.

“…Perphenazine is used as one of several drugs in modern anti-nausea regimens during chemotherapy particularly when one is aiming for "zero tolerance" [87]. Perphenazine and other D2 inhibiting drugs are non-inferior to the more modern drugs of the 'setron group (like ondansetron, granisetron, etc) [3,88]. Anti-nausea effects of perphenazine are additive with 5-HT3 antagonists, NK-1 antagonists and steroids.…”

“…It has been in continuous use since the 1950's to treat psychotic states and conditions [1,2]. Perphenazine is also used to reduce nausea [3], or to calm people who are in an acutely disorganized agitated state. It also has adjunctive use in treating depression.…”