Oral Mosapride Can Provide Additional Antiemetic Efficacy Following Total Joint Arthroplasty Under General Anesthesia

A Randomized, Double-blinded Clinical Trial

Jinwei Xie; Yingchun Cai; Jun Ma; Qiang Huang; Fuxing Pei

Disclosures

BMC Anesthesiol. 2020;20(297) 

In This Article

Background

Total hip and knee arthroplasty remain one of the most commonly performed major orthopedic procedures; the number of procedures in most countries has increased rapidly over the past decades.[1,2] Postoperative nausea and vomiting (PONV) are one of the most common and distressing complications after surgery, especially when the surgery is performed under general anesthesia: PONV occurs in 25–30% of all patients, and the rate can reach 80% among at-risk patients without prophylactic intervention.[3,4] PONV can lead to dehydration, hypertension and other postoperative morbidities, which may prolong hospital stay and increase risk of readmission, raising healthcare costs.[5] This was a paradox in the circumstance that surgeons and healthcare providers have been shifting their focus from the surgical technique to perioperative management in order to improve patients' psychological and functional recovery.[6]

Several prophylactic interventions have been reported to prevent and treat PONV, e.g. 5-HT3 receptor antagonists, NK-1 receptor antagonists, corticosteroids, butyrophenone and antihistamines.[7] While these measures can be effective, PONV remains a persistent problem.[8,9] One reason for this persistence is the gap between implementation and our goal of a "PONV-free hospital". We previously found that PONV occurred in up to 48.8% of patients undergoing total joint arthroplasty under general anesthesia at our medical center (unpublished data). Another reason for this persistence is that anti-PONV measures can be associated with adverse effects. For example, use of the 5-HT3 receptor antagonist ondansetron can aggravate the postoperative constipation that occurs in up to 65% of total joint arthroplasty patients.[10] We have shown that low-dose dexamethasone can reduce the incidence of PONV following total hip and knee arthroplasty,[11,12] but it can be contraindicated in the presence of diabetes or gastrointestinal ulcers. Therefore, it's necessary and practical to search for other antiemetic protocol.

The major risk factor of PONV is use of opioids, which can stimulate the release of 5-HT and inhibit gastrointestinal peristalsis[13]]. Indeed, selective 5-HT4 agonists can stimulate the gastrointestinal tract and promote motility.[14] The selective 5-HT4 agonist mosapride can reduce vomiting caused by chemotherapy.[15] This inspired us to examine whether the anti-emetic effects of oral mosapride might offer clinical benefits for total joint arthroplasty patients.

Thus, we sought to determine in the present study (1) whether the addition of prophylactic oral mosapride to a protocol including dexamethasone and ondansetron can further reduce PONV compared with ondansetron alone or the combination of both; and (2) whether preemptive application of oral mosapride can provide additional clinical benefits for recovery of bowel function and appetite.

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