A factorial trial of six interventions for the prevention of postoperative nausea and vomiting.
Apfel CC, Korttila K, Abdalla M, et al. The New England journal of medicine 2004 · PMID 15190136 · doi:10.1056/nejmoa032196
- Question
- How effective are individual antiemetic and anaesthetic strategies, alone and combined, at preventing PONV?
- Design
- Large multicentre randomised factorial trial testing six interventions.
- Patients
- Adults at high risk of PONV undergoing elective surgery under general anaesthesia.
- Intervention
- Ondansetron, dexamethasone, droperidol, propofol instead of volatile anaesthetic, nitrogen instead of nitrous oxide, remifentanil instead of fentanyl
- Comparison
- Absence of each intervention (factorial design)
- Primary outcome
- PONV within 24 hours of surgery
- Key result
- Ondansetron, dexamethasone and droperidol each reduced PONV risk by roughly a quarter, and propofol and avoiding nitrous oxide also helped; the effects were independent and additive, so combining interventions reduced risk further.
- Limitations
- Conducted in a high-risk population under general anaesthesia; some drugs and techniques have changed in availability since.
- Impact on practice
- Underpins multimodal, risk-stratified PONV prophylaxis (for example dexamethasone plus ondansetron) used in enhanced recovery pathways after arthroplasty.