Pharmacologic interventions for postoperative nausea and vomiting after thyroidectomy: A systematic review and network meta-analysis

Abstract

Objective: To determine the effectiveness of pharmacologic interventions for preventing postoperative nausea and vomiting (PONV) in patients undergoing thyroidectomy.

Design: Systematic review and network meta-analysis (NMA).

Data sources: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar.

Eligibility criteria, participants, and interventions: Randomized clinical trials that investigated the efficacy of pharmacologic interventions in preventing PONV in patients undergoing thyroidectomy were included. The primary endpoints were the incidences of postoperative nausea and vomiting (PONV), postoperative nausea (PON), postoperative vomiting (POV), use of rescue antiemetics, and incidence of complete response in the overall postoperative phases. The secondary endpoints were the same parameters assessed in the early, middle, and late postoperative phases. The surface under the cumulative ranking curve (SUCRA) values and rankograms were used to present the hierarchy of pharmacologic interventions.

Results: Twenty-six studies (n = 3,467 patients) that investigated 17 different pharmacologic interventions were included. According to the SUCRA values, the incidence of PONV among the overall postoperative phases was lowest with propofol alone (16.1%), followed by palonosetron (27.5%), and with tropisetron (28.7%). The incidence of PON among the overall postoperative phases was lowest with propofol alone (11.8%), followed by tropisetron and propofol combination (14%), and ramosetron and dexamethasone combination (18.0%). The incidence of POV among the overall postoperative phases was lowest with tropisetron and propofol combination (2.2%), followed by ramosetron and dexamethasone combination (23.2%), and tropisetron alone (37.3%). The least usage of rescue antiemetics among the overall postoperative phases and the highest complete response was observed with tropisetron and propofol combination (3.9% and 96.6%, respectively).

Conclusion: Propofol and tropisetron alone and in combination, and the ramosetron and dexamethasone combination effectively prevented PONV, PON, POV in patients undergoing thyroidectomy, with some heterogeneity observed in this NMA of full-text reports. Their use minimized the need for rescue antiemetics and enhanced the complete response.

Trial registration number: CRD42018100002.

Fig 1. PRISMA flowchart of included and excluded trials.

Fig 2. Network plot of included studies comparing different pharmacological strategies.

A: PONV, B:.PON, C1: POV, C2: POV excluding separate loops, D: use of rescue anti-emetics. E1: complete response, E2: complete response excluding separate loops. The nodes show a comparison of pharmacological regimens to prevent PONV and the edges show the available direct comparisons among the pharmacological regimens. The nodes and edges are weighed on the basis of the number of included patients and inverse of standard error of effect.

Fig 3. Expected mean ranking and SUCRA values for PONV.

A. X-axis corresponds to expected mean ranking based on SUCRA (surface of under cumulative ranking curve) value, and Y-axis corresponds to SUCRA value. Fig 3B. Expected mean ranking and SUCRA values for PON. X-axis corresponds to expected mean ranking based on SUCRA (surface of under cumulative ranking curve) value, and Y-axis corresponds to SUCRA value. Fig 3C. Expected mean ranking and SUCRA values for POV. X-axis corresponds to expected mean ranking based on SUCRA (surface of under cumulative ranking curve) value, and Y-axis corresponds to SUCRA value. Fig 3D. Expected mean ranking and SUCRA values for use of rescue anti-emetics. X-axis corresponds to expected mean ranking based on SUCRA (surface of under cumulative ranking curve) value, and Y-axis corresponds to SUCRA value. Fig 3E. Expected mean ranking and SUCRA values for complete response. X-axis corresponds to expected mean ranking based on SUCRA (surface of under cumulative ranking curve) value, and Y-axis corresponds to SUCRA value.