Exploration of Postoperative Nausea and Vomiting
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Transcript of Exploration of Postoperative Nausea and Vomiting
An Exploration of PONV and Updated Guidelines for
Prophylaxis:A Recipe for Success
Brittany Benson BSN, SRNA Carolyn Hartle BSN, SRNA
Camille Higdon BSN, SRNA & Kate Saftner BSN, SRNA
Wake Forest Baptist Nurse Anesthesia Program
Objectives
● Review the pathophysiology of PONV
● Describe the risk factors associated with PONV
● Review updated guidelines for PONV prophylaxis
What is PONV?
● Nausea
● Retching
● Vomiting
Pathophysiology
Chemoreceptor Trigger Zone
Identify Adults at Risk
You can’t bake a cake without a recipe…
PONV Risk Factors with New Order of Importance
• Predictors: Female gender > history of PONV >
nonsmoking status > history of motion sickness > age
• Anesthesia related predictors: volatiles > duration of
anesthesia > postop opioid use > nitrous oxide
Independent Risk Factors
• Most likely cause of PONV are volatiles, nitrous oxide, and postoperative opioids
• Volatiles:
o Dose Dependent
o Prominent in first 2-6 hours after surgery
• Opioids:
o Dose Dependent
o Lasts for as long as opioids are used during postoperative period
o No difference among opioids
Type of Surgery
• Still Debated
• Higher Risks: Cholecystectomy, gynecological, and laparoscopic
• Independent Factor?
o Abdominal Surgeries
Commonly Believed Risk Factors...
• Not Clinically Relevanto Anxiety
• Uncertaino menstrual cycle, neostigmine, and perioperative fasting
• Disproveno NG tube, obesity, and supplemental oxygen
Risk Score
•• Based on Independent Predictors + Patient’s Baseline
Risk
• Apfel Score
o 0-1 = low , 2-3 = medium, 4 or more = high
o 0 (10%), 1 (20%), 2 (40%), 3 (60%), and 4 (80%)
Reduce Risk Factors
Avoid General Anesthesia
Avoid Volatiles
Utilize Propofol Infusions
Avoid Nitrous Oxide
Minimize Perioperative Opioids
Provide Adequate Hydration
PONV Prophylaxis: Interventions
New Information!• Palonosetron
• Aprepitant (Emend)
• Haldol
• Midazolam
• P6 and Median Nerve Stimulation
Combinations• Midazolam + Dexamethasone
• Dexamethasone (8mg) + Ondansetron IV (4mg) + Ondansetron (8mg) PO
• Haloperidol (2.5mg) + Dexamethasone (5mg)
• Aprepitant (Emend) (40mg) + Dexamethasone (10mg)
Recommended Dosages and Timing
PONV: Drug Therapies5-HT3 Receptor Antagonists
o Ondansetron, Dolasetron, Palonosetron
NK-1- Receptor Antagonist
o Aprepitant (Emend)
Corticosteroids
o Dexamethasone
Butyrophenones
o Droperidol, Haloperidol
Antihistamines
Anticholinergics
o Transdermal Scopolamine
Phenothiazines
o Metoclopramide
Propofol
Gabapentin
Midazolam
P6 and Median Nerve Stimulation
Frey UH, Funk M, Lohlein C, Peters J. P6 acustimulation effectively decreases postoperative nausea and vomiting in high-risk patients undergoing a laparoscopic cholecysectomy. Acta Anaestesiol Scand 2009;102:620-5
Meta-analysis• 40 articles
• 4,858 subjects
Efficacy• similar to ondansetron and
droperidol
Timing
Combined Therapies
• NEW GUIDELINE - Adults at Moderate Risk for
PONV
o Administer PONV Prophylaxis using
1-2 Interventions
• NEW GUIDELINE - Adults at High Risk for PONV
o Administer PONV Prophylaxis using
2 or more Interventions
PONV Prevention and Treatment Implementation in Clinical Setting•• Valid Assessment of patient’s risks
• Management strategy based on patient preference, cost efficiency, preexisting conditions
Cost of Antiemetics
• PONV prophylaxis is cost effective with older, less expensive drugs when patients have a 10% or more risk of emesis
• Newer drugs have significant costs
Clinical Effectiveness of PONV protocols• Protocols have been poorly implemented for both adults
and children.
• Even after continuous feedback and training, 47% of moderate, and 37% of high risk patients received prophylactic treatment when using a simple algorithm of 1 antiemetic per risk factor in the preop assessment.
• Almost everyone received the single antiemetic prophylaxis no matter what their risk factors were.
NEW RECOMMENDATIONS:Risk-Adapted PONV Prevention Algorithm
LOW MEDIUM HIGH
Interventions
for prophylaxis
NO prevention,
Wait and see
Decadron + Zofran or
TIVA
Decadron + Zofran
+TIVA, case by case
may use further
intervention
Interventions for
treatment
1. Zofran
2. Droperidol in
case first doesn’t
work
1.Droperidol
2.Dimenhydrinate
if first doesn’t work
1.Droperidol
2.Dimenhydrinate if
first doesn’t work
PONV Prevention Algorithm in all Patients
LOW MEDIUM HIGH
Interventions for
Prophylaxis
Dexamethasone + (Zofran or
TIVA)
Dexamethasone + (Zofran or
TIVA)
Dexamethasone + Zofran
+TIVA
On case by case decision to
use further interventions
Interventions for
Treatment
1. Droperidol
2. Dimenhydrinate if first doesn’t
work
1. Droperidol
2. Dimenhydrinate if first
doesn’t work
1. Droperidol
2.Dimenhydrinate
if first doesn’t work
Conclusion
• The goal is for antiemetic multi modal prevention to become an integral part of anesthesia.
• Management strategy includes patient preference, Cost efficiency, and level of PONV risk.
• Different drug classes have additive effects
• Rescue therapy should not include the same drugs used as prophylaxis
References
• Becker, DE., Nausea vomiting and hiccups: a review of mechanisms and treatment. Anesthesia Progress. 201o, 57.
• Guyton, AC., Hall, JE., Testbook of Medical Physiology. 11th ed. Philadelphia, Pa: Elsevier; 2006
• Tong J., Diemunsch, P., Ashraf SH., et al. Consensus guidelines for the management of postoperative nausea and vomiting. Society for Ambulatory Anesthesiology. 2014, 114(1).
• Wilhelm, SM., Dehoorne-Smith, ML., Kale-Pradhan, PB., Prevention of Postoperative Nausea and Vomiting. The Annals of Pharmacology. 2007, 41(1).
• American Society of Health-System Pharmacists. (2014). Received from http://www.ashp.org/menu/DrugShortages/CurrentShortages/