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/