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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 35  |  Issue : 3  |  Page : 265-269

Oral gabapentin premedication for post-tonsillectomy nausea, vomiting, and recovery


1 Department of Anesthesia and Intensive Care, Faculty of Medicine, Benha University, Benha, Egypt
2 ICU Department, Senbellawein Hospital, Egypt

Date of Submission16-Feb-2018
Date of Acceptance30-Apr-2018
Date of Web Publication07-Jan-2019

Correspondence Address:
Dr. Mohammed M.A Esmael
23 Khaled Ibn Elwaleed Street, Elnozha, Elsinbillawen, Dakahlia, 35768
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bmfj.bmfj_24_18

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  Abstract 


Background Gabapentin is a second-generation anticonvulsant that is successful in the management of chronic neuropathic pain. It was not previously known to be useful in acute perioperative conditions, but recently it has been used for acute perioperative conditions. However, evidence-based medicine suggests that perioperative administration is useful for postoperative analgesia, preoperative anxiolysis, attenuation of the hemodynamic response to laryngoscopy and intubation, and preventing chronic postsurgical pain, postoperative nausea and vomiting (PONV), and delirium. This article reviews the clinical trial data to describe the efficacy and safety of gabapentin for perioperative anesthetic management.
Aim The aim of the study was to evaluate and update the effect of preoperative gabapentin on the incidence of postoperative vomiting and on analgesic requirements after adenotonsillectomy in pediatrics.
Materials and methods This randomized, double-blind study was designed to explore the possible effects of oral gabapentin as a premedication on the incidence and severity of PONV and on the early recovery profile of pediatric patients undergoing adenotonsillectomy under sevoflurane anesthesia.
Results The incidence of PONV in the gabapentin group was significantly lower than in the gabapentin group. However, the numbers of rescue ondansetron doses and the PONV severity score were comparable in the two groups.
Conclusion The use of gabapentin as premedication in pediatric patients undergoing adenotonsillectomies under sevoflurane anesthesia reduces the incidence of PONV and emergence agitation in the early postoperative period. However, gabapentin did not reduce pain and analgesic consumption after surgery.

Keywords: gabapentin, premedication, postoperative nausea, vomiting


How to cite this article:
Moety IM, El Barbari DH, Esmael MM. Oral gabapentin premedication for post-tonsillectomy nausea, vomiting, and recovery. Benha Med J 2018;35:265-9

How to cite this URL:
Moety IM, El Barbari DH, Esmael MM. Oral gabapentin premedication for post-tonsillectomy nausea, vomiting, and recovery. Benha Med J [serial online] 2018 [cited 2019 Oct 17];35:265-9. Available from: http://www.bmfj.eg.net/text.asp?2018/35/3/265/249423




  Introduction Top


Postoperative nausea and vomiting (PONV) remains to be one of the most common and worst complications after surgery and it is known that PONV is multifactorial, with a reported occurrence ranging from 23 to 73% [1]. Prevention and management of PONV by the multimodal approach includes both pharmacological and nonpharmacological measures [2]. Multiple drugs were used to prevent and treat PONV after adenotonsillectomy in children, for example ondansetron, metoclopramide, antihistamines, and dexamethasone [3]. The gabapentinoids (pregabalin and gabapentin) are both used for the treatment of postherpetic neuralgia and as an adjuvant therapy for convulsions in adults and in children. However, studies confirmed that the use of gabapentin in adults perioperatively is beneficial for preoperative anxiolysis [4], postoperative pain management [5], reduction of the hemodynamic response to laryngoscopy and intubation [6], reduction of PONV, and delirium [7]. The use of gabapentinoids for the management of PONV was not evaluated in pediatrics until now.


  Materials and methods Top


A written informed consent was obtained from the parents. Children aged 3–12 years, scheduled for adenotonsillectomy were recruited. The study was approved by the Research Ethical Committee and an informed consent was obtained from each participant before enrollment in the study. Patients who had active infection, obstructive sleep apnea, cognitive impairment, abnormal bleeding profile, renal or hepatic dysfunction, and history of allergic reaction to study medications or chronic use of anticonvulsants were excluded.

Study groups

Control placebo group (group C)

Patients in this group received 0.3 ml/kg of a placebo solution identical in taste, shape, and color to the study medication 2 h before induction of anesthesia.

Gabapentin group (group GAB)

Patients in this group received 0.3 ml/kg (16 mg/kg) oral gabapentin solution (neurontin 50 mg/ml; Pfizer Pharmaceutical; PARKE-DAVIS DIV OF PFIZER INC., NY, NY) as premedication 2 h before the induction of anesthesia.

Study outcome measures

Primary outcome measure

Composite incidence of PONV.

Secondary outcome measures

  1. Pediatric anesthesia behavior score during inhalation induction of anesthesia.
  2. Incidence and severity of postoperative delirium.
  3. Duration of recovery and discharge from the postanesthesia care unit.
  4. Time to first request of postoperative rescue analgesics.
  5. Objective pain scale.


Statistical analysis

Normally distributed continuous data are presented as mean and SD. Non-normally distributed continuous and ordinal data are expressed as median (range). Categorical data are expressed as number of patients and incidence. Unpaired t-test was used to compare continuous data in the two groups. Repeated measure analysis of variance with post-hoc Dunnett’s test was used to compare changes in continuous variables in relation to the baseline preoperative values. χ2-test or Fisher’s exact test was used as appropriate to compare categorical data. For all statistical comparisons a P value of less than 0.05 was considered significant. All data analyses and graphical demonstrations were done using the Statistical Package for the Social Sciences (SPSS) software (SPSS Inc., Chicago, Illinois, USA).


  Results Top


The total number of patients who fulfilled the inclusion criteria was 142; two patients were excluded due to postoperative bleeding and 140 patients who completed the study patients’ characteristics were comparable in the two study groups.

The incidence of PONV in the gabapentin group was significantly lower than in the gabapentin group. However, the numbers of rescue ondansetron doses and the PONV severity score were comparable in the two groups.

The objective pain scale in the first 6 h postoperatively was comparable in the two study groups with no statistically significant difference at all assessment points.


  Discussion Top


In the present study, we found that the use of oral gabapentin as premedication in pediatric patients undergoing adenotonsillectomies under sevoflurane anesthesia reduced the incidence of PONV and emergence agitation in the early postoperative period. The mode of action of gabapentin in the prophylaxis of PONV is still not known, but it could be due to the indirect action by opioid sparing or a direct action on tachykinin activity [8]. These results in agreement with previous studies showed that the preoperative gabapentin use in adults who are undergoing abdominal surgery is resulted in a significant decrease in the occurrence of postoperative nausea (relative risk: 0.76; 95% confidence interval: 0.58–0.98) and postoperative vomiting (relative risk: −0.62; 95% confidence interval: 0.45–0.85) [9].

Gabapentin has an indirect useful action on physiological recovery postoperatively secondary to optimal pain management.

Perioperative gabapentin significantly increased the peak expiratory flow rate after surgery when compared it with placebo on days 1 and 2 after surgery (P≤0.002) after abdominal hysterectomy [10]. Perioperative gabapentin significantly increased forced vital capacity and peak expiratory flow rate at 24 h (P≤0.005; P≤0.024) and 48 h (P≤0.005; P≤0.029) after thoracotomy surgery [11]. Gabapentin has been shown to be useful in decreasing nausea produced by chemotherapy in an open label preliminary research.

Our findings in the pediatric sample are generally in line with the trends reported with the use of preoperative gabapentin in adults undergoing laparoscopic [12] or open cholecystectomy [13]. A recent quantitative analysis of evidence from randomized, controlled trials (RCTs) in adults was supportive for the use of preoperative gabapentin in PONV prophylaxis, especially in abdominal surgeries. Interestingly, they found that the benefits of gabapentin appeared to be reduced in patients who received propofol [14].

Dauri et al. [15] evaluated the effect of gabapentin and pregabalin on postoperative pain management and its effect on PONV and side effects like dizziness and sedation. This review found an overall of 22 gabapentin (1640 patients), eight pregabalin (707 patients) RCTs, and seven meta-analysis from 2006 to 2009. Fourteen RCTs and four RCTs showed that gabapentin and pregabalin, respectively, did not reduce PONV when compared with placebo. Three RCTs that studied the gabapentin alone [12] or its combination with dexamethasone [16] or rofecoxib [17] found a significant reduction of PONV in the gabapentin group compared with the placebo [12],[16],[17]. Gabapentin and dexamethasone combination seems to have a synergic effect on reducing PONV in comparison with gabapentin or dexamethasone alone [16].

The Society of Ambulatory Anesthesiology consensus guidelines for the management of PONV [18] stated that gabapentin at a dose of 600 mg given 2 h before surgery could effectively decrease PONV in adults and if given 1 h before surgery, gabapentin 800 mg is as effective as dexamethasone 8 mg intravenously, and the combination is better than either drug alone. The guidelines recommended the use of subhypnotic doses of propofol combined with dexamethasone for the reduction of PONV in preschool children undergoing adenotonsillectomy.

Smith has defined nausea as a bad sensation and unpleasant emotion, which may be described in terms of a ‘sick’ sensation with or without a sense of impending vomiting/retching − often associated with a perception of epigastric or upper abdominal discomfort or awareness.

Nausea may be combined with autonomic-driven physiologic changes of pallor, diaphoresis, changes in heart rate (tachycardia or bradycardia), upper gastrointestinal tract hypersecretion, and opening of the gastric fundus and cardia [19].

Vomiting results from a coordinated contraction of predominantly abdominal muscles and diaphragm, whereas the gastric cardia is open and elevated with contracted pylorus leading to expulsion of the gastric contents from the mouth [20].

The degree of distress/suffering from nausea/vomiting occurring in the patient varies dramatically and should be well evaluated. Some patients suffering from nausea and they choose to have some degree of pain sensation with no nausea [21]. Other studies have shown significant effects on the quality of life of patients also [22].

There is no well-defined discrete vomiting center. The terminology ‘emetic complex’ should replace the term vomiting center − to describe groups of loosely organized neurons distributed inside the medulla that are sequentially stimulated by a central pattern generator and having a great role in vomiting.

The emetic complex is formed of the prodromal-sign center (located in the reticular area dorsally close to the semicompact part of the nucleus ambiguous) and the central pattern generator center (located dorsomedial to the retrofacial nucleus). The prodromal-sign center predominantly composed of central pattern generator-driving neurons and prodromal-sign neurons. The central pattern generator center (for vomiting) appears to have afferent sites for expulsion and retching [20].

While the occurrence of PONV varies considerably in both the inpatient and outpatient setting [23], multiple studies show that the occurrence of nausea ranges between 22 and 38% and the occurrence of vomiting ranges between 12 and 26% [24].

The occurrence of PONV in high-risk patients is more (60–70%) in the presence of multiple risk factors [25].

The administration of antiemetic drugs decreases this occurrence, especially when multiple antiemetics are used [26].

The use of one antiemetic results in minimal effects, so the multimodal approach using multiple drugs is tried [27] and found that multiple drug therapies minimized the occurrence of PONV [28].

The average occurrence of PONV in childhood is 30–80% and can be double the occurrence in adults [29]. This high occurrence needs the use of antiemetic as a prophylaxis instead of therapy. Eberhart and colleagues [30],[31] identified four risk factors for PONV in pediatric anesthesia: previous PONV or a positive family history, duration of anesthesia (>30 min), age (>3 years), and strabismus surgery. The risk of PONV was predicted as 9, 10, 30, 55, and 70%, respectively, depending on the presence of 0, 1, 2, 3, and 4 risk factors.The occurrence of postdischarge nausea and vomiting in children differs according to the type of surgery. Post-tonsillectomy, 20% of children complains of postdischarge nausea and vomiting on day 3 and 8% on day 7 [32],[33],[34].

Gabapentin is a second-generation anticonvulsant that is successful in the management of chronic neuropathic pain. It was not previously known to be useful in acute perioperative conditions but recently it is used. However, evidence-based medicine suggests that perioperative administration is useful for postoperative analgesia, preoperative anxiolysis, attenuation of the hemodynamic response to laryngoscopy and intubation, and preventing chronic postsurgical pain, PONV, and delirium.

Gabapentin was primarily used in 1993 as an assistant antiepileptic drug for the treatment of refractory partial fits. Subsequently, it was known to be successful in treating different chronic pain conditions, like postherpetic neuralgia, diabetic neuropathy, complex regional pain syndrome, inflammatory pain, central pain, malignant pain, trigeminal neuralgia, HIV-related neuropathy, and headaches [35].


  Conclusion Top


The use of oral gabapentin as a premedication in pediatric patients undergoing adenotonsillectomies under sevoflurane anesthesia reduced the incidence of PONV and emergence agitation in the early postoperative period. However, gabapentin did not reduce pain and analgesic consumption after surgery.

Acknowledgements

The author expresses his gratitude to ALLAH to whom he relates all his success in life and to all members of the Anaesthesia Department, Faculty of Medicine, Benha university.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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