The most common and distressing symptoms, which follow anaesthesia and surgery, are pain and emesis. The consequences of PONV are physical, surgical and anesthetic complications for patients as well as financial implications for the hospitals or institutions. Sometimes nausea and vomiting may be more distressing especially after minor and ambulatory surgery, delaying the hospital discharge. Laparoscopic surgery is one condition, where risk of PONV is particularly pronounced due to pneumo-peritoneum causing stimulation of mechanoreceptors in the gut. In spite of plenty of anti-emetic drugs available no single drug is 100% effective in prevention of PNV and combination therapy has got a lot of side effects.

1. Comparison of Ondansetron and Granisetron for Prevention of
Nausea and Vomiting Following Day–Care Abdominal
Laparoscopies

2. Original Article
INTRODUCTION
The most distressing symptoms that follow anesthesia
and surgery are pain and vomiting.The syndrome of nausea,
retching and vomiting is known as ‘sickness’ and each part
of it can be distinguished as a separate entity. Sometimes
nausea and vomiting may be so distressing that it can affect
the patient psychologically, physically and financially by a
delay in hospital discharge. With the change in focus from
inpatient to ambulatory anesthesia, there has been an
increased interest in the “Big Little Problem” of nausea and
vomiting [1,2].The etiology and pathophysiology of PONV
are multifactorial with patient, medical and surgery related
factors [3,4]. Three patients related variables i.e. female
gender, smoking and age; 2 operative variables like duration
of surgery, types of surgery (laparoscopic surgery, strabismus
surgery) and 3 anesthesia related variables i.e. use of opioids
intraoperatively, N2O and intravenous anesthesia with
Propofol. Various pharma-cologic agents are rapidly coming
up with increasing efficacy to prevent and treat PONV. The
newer classes of antiemetics are NK-1 (substance P) receptor
antagonists and Serotonin (5-HT3) receptor antagonists (e.g.
Ondansetron,Granisetron,Dolasetron,Tropisetron,etc.)have
replaced the older traditional antiemetics like Phenothiazines
(promethazine), antihistamines (diphenhydramine),
Butyrophenones(drop-eridol),steroids(dexamethasone)and
Benzamides (metoclopramide) because of their side effects
and lesser efficacy [5].
COMPARISON OF ONDANSETRON AND GRANISETRON FOR
PREVENTION OF NAUSEAAND VOMITING FOLLOWING DAY–
CARE ABDOMINAL LAPAROSCOPIES
Ankur Parmar*, V Manjula** and JM Reddy***
*Registrar, Department of Anesthesiology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India,
**Consultant, ***Senior Consultant, Department of anesthesiology, Apollo Health City,
Jubilee Hills, Hyderabad 500 033, India.
Correspondence to: Dr Ankur Parmar, Registrar, Department of Anesthesiology, Indraprastha Apollo Hospitals,
Sarita Vihar, New Delhi, 110 076, India.
The most common and distressing symptoms, which follow anaesthesia and surgery, are pain and emesis.
The consequences of PONV are physical, surgical and anesthetic complications for patients as well as
financial implications for the hospitals or institutions. Sometimes nausea and vomiting may be more
distressing especially after minor and ambulatory surgery, delaying the hospital discharge. Laparoscopic
surgery is one condition, where risk of PONV is particularly pronounced due to pneumo-peritoneum causing
stimulation of mechanoreceptors in the gut. In spite of plenty of anti-emetic drugs available no single drug is
100% effective in prevention of PNV and combination therapy has got a lot of side effects.
Key words: Ondansetron, Post-anesthesia Vomiting, Granisetron.
Laparoscopy is a technique of minimal invasive
surgery. The hallmark of laparoscopy is the creation of
‘pneumoperi-toneum’ with pressurized CO2 which results
in a high incidence of Post Operative Nausea and
Vomiting (PONV) (40-75% of patients) [6,7].
Laparoscopic procedures are regarded as standard
operations for the study of PONV. The present study was
carried out to examine the incidence of nausea and
vomiting following – laparoscopic cholecystectomy and
compare the efficacy of granisetran Ondansetrom in its
management [8-11].
The aim and objectives
To compare the anti-emetic and anti-nausea effect,
incidence of PONV, duration of action and cost
effectiveness of intravenous Granisetron (1 mg) and
Ondansetron (8 mg) in a randomized double blind study
for prophylaxis of post operative nausea and vomiting
(PONV) in ASA grade I and II adult patients undergoing
abdominal laparoscopies under general anaesthesia.
MATERIALS & METHODS
The study was carried out at Apollo Health City,
Hyderabad from May 2008–October 2009 after obtaining
due institutional approval and informed written consent
from 60 patients.
Apollo Medicine, Vol. 8, No. 2, June 2011 126

3. Original Article
127 Apollo Medicine, Vol. 8, No. 2, June 2011
INCLUSION CRITERIA
(i) Patients ofASAGrade I & II,
(ii) Patients aged between 30-60yrs,
(iii) Patients belonging to either sex,
(iv) Patients weighing between 40-80kg,
(v) Patients scheduled for day care abdominal
laparoscopic surgeries in the surgery department of
the hospital.
EXCLUSION CRITERIA
(i) Patients with any known systemic, metabolic or
endocrine disorder,
(ii) Patients with known allergy to the drugs under study,
(iii) Patients with history of PONV, Gastro esophageal
reflux disease & motion sickness,
(iv) Patients with anticipated airway difficulty,
(v) Uneducated patients who were unable to cooperate
with the investigator.
STUDY TYPE: Prospective, randomized,
comparative, double blinded study.
METHOD
The pre-anesthetic check of the patients was done a
day before surgery. The patients were randomly divided
into two groups using the coin flip method:
• Group A (n=30): IV injection Ondansetron 8mg
diluted in normal saline to a total volume of 5mL
administered 2 minutes before induction.
• Group B (n = 30): IV injection Granisetron diluted in
normal saline to a total volume of 5mL administered
2 minutes before induction.
PREOPERATIVE PREPARATION
All the patients were allowed to take light and non-
residual diet in the evening of previous day of operation.
All of them received tab. Alprazolam 0.5mg and tab.
Ranitidine 150mg orally night before surgery. All the
patients were advised to remain nil per oral after midnight.
ANESTHETIC TECHNIQUE
Study medications were prepared and administered
just 2 minutes before induction by anesthetist in identical
5-mL syringes to ensure blinding.
General anesthesia was induced with inj. Propofol
(1%) 2mg/kg IV, inj. Vecuronium 0.08mg/kg IV and inj.
Fentanyl 100 mcg IV. Endotracheal intubation was done
with appropriate sized cuffed ETT. A nasogastric tube was
placed orally to promote baseline emptying of the
stomach of air and gastric contents.
Maintenance of anesthesia was done with oxygen and
nitrous oxide at the ratio of 1:2, sevoflurane 1% and
intermittent positive pressure ventilation facilitated by
intermittent doses of inj. Vecuronium 1mg IV. The
peritoneal cavity was insufflated with CO2 Pneumo-
peritoneum was established, intraabdominal pressure
maintained around 10-15 mmHg. The IV fluid used during
surgery was 0.9% saline. Pulse, blood pressure,
electrocardiogram, oxygen saturation and end tidal
carbondioxide values were monitored throughout
anesthesia.
At the end of surgery the patients were extubated after
the residual neuromuscular block was reversed with inj.
Neostigmine 0.05mg/kg & inj. Glycopyrrolate 0.02mg /kg
slow IV, and shifted to the recovery room.
OBSERVATIONS
The observations were recorded as per the following
protocol:
1. Pulse rate, blood pressure (BP) and oxygen
saturation (SPO2) were recorded prior to the
induction.
2. Intraoperative pulse, BP, SPO2 and end tidal carbon
dioxide (ETCO2) were recorded throughout the
surgery and the mean was calculated.
3. All the patients were asked for nausea and were
observed for vomiting.
- Every 1 hourly for 2 hours (i.e. at 0, 1st and 2nd
hours)
- Every 2 hourly till 6th hour (i.e. at 4th and 6th
hour)
- At 12th hour then at 24hrs (through phone calls)
4. The incidence of postoperative nausea and vomiting
were scored as per the following scoring system as
proposed by M. Dresner, et al [13].
Postoperative Nausea Score Postoperative
Vomiting score
0–None 0–None
1–Mild intermittent nausea 1–One vomit only
2–Constant modulate nausea 2–Several vomits
3–Severe nausea 3–Repeated retching/
vomiting

4. Original Article
Apollo Medicine, Vol. 8, No. 2, June 2011 128
5. Nausea and vomiting were evaluated by the
following variables: the incidence of nausea and
vomiting, episodes of vomiting, rescue antiemetics,
and complete responses. For the purpose of data
collection, retching (same as vomiting but without
expulsion of gastric content) was considered
vomiting. A vomiting episode was defined as the
events of vomiting that occurred in a rapid sequence
(<1 min between events). If events of vomiting
were separated by >1 min, they were considered
separate episodes.
6. The instruction was given that the patients with >2
episodes of vomiting should receive Inj. Dexa-
methasone (8mg) IV stat as rescue medication [14].
7. The complete response was defined as no nausea, no
vomiting, and no antiemetic medication during a 24-
h postoperative period.
STATISTICALANALYSIS
Data was represented as mean ± standard deviation
wherever applicable. The 2 groups were compared
categorically for nausea and vomiting.A p-value <0.05 was
taken as statistically significant by student’s t-test. The
software used in the study was WINDOSTAT version 8.6.
OBSERVATIONS
Table 1 shows the age, sex & body weight distribution
in the 2 groups of patients. There was no significant
difference in age, sex and body weight distribution in the
two groups.
Table 2 shows the preoperative pulse, blood pressure
(Systolic & diastolic) and SPO2 in the 2 groups of patients.
There was no statistically significant difference in the
baseline values of the patients in the 2 groups.
As per Table 3, none of the cases in the two groups
showed any significant hemodynamic deviation from the
preoperative values in the intraoperative period.
There was statistically no significant difference in the
2 groups in the Table 4, for the type of surgeries which the
patients underwent.
The duration of anesthesia of the patients was
observed in both the groups and the mean value was
calculated for the comparison in each group. There was no
significant difference in the mean duration of anesthesia in
the two groups in the Table 5 (P>0.1).
Figures 1 (a) & 1 (b) show that the patients in group B
did not have nausea in the first 4 hours post operatively
Table 1. Patient demography
Group No. of cases Male(%) Female(%) Age Inyrs. ± Sd Weight in Kg ±Sd
A 30 6 (19.8%) 24 (80.2%) 46.4±9.06 53.0±8.28
B 30 7 (23.3%) 23 (76.7%) 45.7±10.18 54.27±7.77
Table 2. Preoperative pulse, blood pressure & oxygen saturation
Group No. of Pulse Systolic blood Diastolic blood Oxygen saturation
cases (B/M) ± SD pressure pressure SPO2 (%) ± SD
(mm Hg)± SD (mmHg)± SD
A 30 79.53±10.60 123.86±7.99 81.13±4.86 98.83±0.87
B 30 78.86±10.94 121.93±7.94 80.60±5.15 99.23±0.77
Table 3. Intraoperative mean pulse, blood pressure & oxygen saturation
Group No. of Mean pulse Systolic blood Diastolic blood Oxygen saturation
cases (B/M) ± SD pressure pressure SPO2 (%) ± SD
(mm Hg) ± SD (mmHg) ± SD
A 30 79.53±10.61 123.86±7.99 81.13±4.86 100
B 30 78.86±10.94 121.93±7.94 80.60±5.15 100

5. Original Article
129 Apollo Medicine, Vol. 8, No. 2, June 2011
and the incidence of higher scores was also less after 4
hour.
The nausea score in groupA is higher in comparison to
group B. Statistical analysis by student’s t-test indicates
significance at 1 (P=0.027*), 4 (P=0.013*), 6 (P=0.032*),
and 12 hours (P=0.001*) whereas there was no significant
difference observed at 0,2 & 24 hours.
There was no vomiting in group A for first 2 hours and
in group B for the first 12 hours. The vomiting scores
indicated significant statistical difference in vomiting at
12 hours in GroupA(P=0.039*).
Incidence of postoperative nausea & vomiting
In group A patients nausea was observed in 13 patients
(43.33%), vomiting in 12 patients (40%), both nausea &
vomiting in 13 patients (43.33%) & no sickness in 17
patients (56.67%) whereas in group B nausea was
observed in 5 patients(16.67%), vomiting in 2 (6.67%)
cases, both nausea & vomiting in 5 patients (16.67%) & no
sickness in 25 patients (83.33%). Incidence of nausea was
more in group A compared to group B. Incidence of
vomiting was also more in group A. Incidence of sickness
was significantly high in group A. Incidence of no
sickness was significantly more in group B which was
higher than group A (P-value <0.05). It was also observed
that in spite of treatment though incidence of vomiting was
reduced, but nausea was not totally abolished in both the
groups as evident (Figs. 1-6).
DISCUSSION
Postoperative nausea and vomiting are observed after
general, regional and local anesthesia. Reported incidence
of postoperative nausea and vomiting (PONV) after
abdominal laparoscopic surgeries ranges from 40-70%
[6].
The effect of PONV ranges from transient discomfort
to even catastrophic complications like rupture of
esophagus. Other effects are dehydration, electrolyte
disturbances, poor surgical outcome in ophthalmic, head
& neck surgery and abdominal wounds. It limits the
benefit of laparoscopy by delaying hospital discharge and
at times results in an unanticipated overnight admission in
hospital [6].
From the observations of table-1 it was found that
there was no significant difference in age, sex and body
weight (P value >0.1).
In Table 2 and 3, pre-operative and intraoperative
pulse, BP and oxygen saturation of the 2 groups were
studied. The sudden hypotension or hypoxia, which are
positive factor of PONV were not observed. The duration
of anesthesia or the type of surgery done did not show any
marked difference (Table 4 & 5) between the two groups.
The anesthesia time was defined as the time from
anesthetic induction until the patient was shifted to post-
anesthesia care unit.
From observation of the Figure 1 (a) & 1 (b), in Group-
B (Granisetron 1mg) the postoperative nausea score
Table 4. Type of surgery
Group Laparoscopic Laparoscopic Laparoscopic Laparoscopic
cholecystectomy inguinal hernioplasty appendicectomy ventral hernioplasty
GroupA 14(40.67%) 7(2.33%) 7(2.33%) 2(0.67%)
Group B 15(50%) 5(1.67%) 8(2.67%) 2(0.67%)
Table 5. Duration of anesthesia
Group No of Mean duration of
cases anesthesia (min.) ± SD
A 30 78.13 ± 12.11
B 30 77.80 ± 11.24
Table 6. Incidence of postoperative nausea & vomiting
Group No. of cases Nausea Vomiting Total No sickness
A 30 13 (43.33%) 12 (40%) 13 (43.33%) 17 (56.67%)
B 30 5 (16.67%) 2 (6.67%) 5 (16.67%) 25 (83.33%)

6. Original Article
Apollo Medicine, Vol. 8, No. 2, June 2011 130
(a)
(b)
Fig 1. (a) Post operative nausea score – Group A; (b) Post
operative nausea score – Group B
Fig 2. Mean post operative nausea score
(PONS) was significantly lower at 1, 4, 6 and 12 hours
after completion of anesthesia. Post operative vomiting
score (POVS) in Table 6 showed no incidence of vomiting
in patient under Group-B until 12 hours, whereas
vomiting was reported around 4, 6, 12 and 24 hours after
anesthesia in Group A. There was a significant statistical
difference in POVS at 12 hours, P value = 0.034. It shows
that the severity of both nausea and vomiting in the
Granisetron group was significantly less than that in the
Ondansetron group.
From observation in Table 7, response to prophylactic
medication in Group-A and Group-B have shown that 17
(56.67%) and 25 (83.33%) cases remained free from
nausea and vomiting, respectively. The number of cases
who vomited in group B were 2 (6.67%), but it was 12
(40%) case in Group-A. The incidence of nausea in group-
A and B were 13 (43.33%) and 5 (16.67%) cases
respectively. The overall incidence of PONV in Group A
and B were 43.33% and 16.67% respectively. Another
important factor in post-op nausea & vomiting is IV
administration of antibiotics which was not taken into
account in our study.
It has been observed in various studies that antiemetic
therapy is often very effective in reducing incidence of
vomiting or retching, but less so for nausea [17-21].
From the observations in the Table 6, on comparing
the total nausea scores at the end of surgery between group
A and group B it was evident that the duration of
antinausea effect after a single dose of Ondansetron 8mg
was significantly less than that of single dose of
Granisetron 1mg. The nausea score in the Group B was
zero till the end of 4 hours. There was a statistically
significant difference at the end of 1st, 4th, 6th and 12th
hours, with the P values as 0.027, 0.013, 0.032 and 0.001
respectively. Similarly, there were no reported cases of
vomiting in the Granisetron group till the end of 12 hours
which was statistically significant (P = 0.039) when
compared to the vomiting score in the Ondansetron group.
Also, as evident by the higher total scores of nausea and
vomiting in group A, Granisetron 1mg reduces the
severity of nausea and vomiting better than Ondansetron
8mg, the P = 0.003 for total nausea score and P = 0.019 for
Table 7. Total nausea & vomiting score
Group Total nausea score Total vomiting score
(Mean ± SD) (Mean ± SD)
GroupA 1.93 ± 2.74 0.40 ± 0.49
Group B 0.33 ± 0.92 0.13 ± 0.34
P value 0.003 0.019

7. Original Article
131 Apollo Medicine, Vol. 8, No. 2, June 2011
(a) (b)
Fig 3. (a) Post operative vomiting score – Group A; (b) Post operative vomiting score – Group B
Fig 4. Mean post operative vomiting score
Fig 5. PONV incidence in Group A Fig 6. PONV incidence in Group B
total vomiting score comparing both the groups. This
shows that there was a significantly prolonged antinausea
and antiemetic effect with intravenous administration of
Granisetron in the patients undergoing day care abdominal
laparoscopies although there was not a need to administer
the rescue antiemetic or a need of readmission in both the
groups. This implies that the requirement of Granisetron
1mg is twice daily as compared to thrice daily requirement
of Ondansetron 8mg.
Cost is an ever-increasing concern in today’s health
care system. Prophylactic antiemetic with Granisetron is
relatively inexpensive. On comparing the cost of one dose
of inj. Ondansetron 8mg, MRP Rs. 42.00, with one dose of
inj. Granisetron 1mg, MRP Rs. 18.95, it is clearly evident
that the therapy of PONV with Granisetron per dose is

8. Original Article
Apollo Medicine, Vol. 8, No. 2, June 2011 132
approximately 2.21 times cheaper than the treatment with
Ondansetron.
PONV can lead to a number of unwanted side effects
including fluid and electrolyte imbalance, wound
dehiscence, delayed discharge of day care patients, unanti-
cipated hospitalization of day care patients with extra
costs to the patient and the hospital. Increasingly there is a
trend towards day care surgery therefore these last two
factors have become important considerations. PONV can
lead to a lot of stress for the patient, their relatives and
health workers and create major negative impact on
patient satisfaction and overall surgical experience.
CONCLUSION
From the present study, it was concluded that-
• There was no significant hemodynamic difference in
the patients receiving Ondansetron or Granisetron.
• The patients who received Granisetron had signi-
ficantly less severe Post Operative Nausea compared
to the group that received Ondansetron.
• There was a decrease in the incidence of post
operative nausea in the patients receiving
Granisetron as compared to Ondansetron.
• The incidence of post operative vomiting was
significantly less with Granisetron than with
Ondansetron.
• The duration of action of Granisetron was longer
than Ondansetron even when administered at the
start of anesthesia, as evident by the post operative
nausea and vomiting scores.
• The cost effectiveness of the therapy of PONV was
significantly more with Granisetron than with
Ondansetron.
Hence, Granisetron can be used as an antiemetic agent
in abdominal laparoscopic surgeries to reduce the
incidence of postoperative nausea & vomiting.
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