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What’s New with PONV & PDNV?
1100 - 1200
Objectives
• Describe ASPAN EBP postoperative nausea and vomiting (PONV) and Post discharge nausea and Vomiting (PDNV) clinical practice guideline
• Describe algorithm for prevention and treatment of nausea and vomiting.
PONV/PDNV* Clinical Practice Guideline 3 in
Part IV of ASPAN Standards
• Most common complication affecting 1/3 of surgical patients (75 million individuals)
• PONV is a strong predictor of:–Prolonged postoperative stay–Unanticipated admissions– Financial impact• Costs several million dollars each year
ASPAN Clinical Practice Guideline for Prevention &/or Management of PONV/PDNV 2010
PONV
• Reported as – Common fear prior to elective surgery– More debilitating than postop pain or surgery itself
• Adverse impact of PONV & PDNV include– Aspiration– Wound dehiscence– Prolonged hospital stay– Unanticipated hospital admission– Delayed return of patient’s functional ability– Lost time from work for patient & caregiver
ASPAN Clinical Practice Guideline for Prevention &/or Management of PONV/PDNV 2010
DefinitionsNAUSEA
Subjective report of an unpleasant feeling in the epigastrum &/or in the back of the throat
“Feeling sick to my stomach”
”Feeling queasy” “Turning stomach” “Feeling squeamish”
VOMITING
Forceful expulsion of contents of stomach, duodenum & jejunum through the oral cavity as a result of change in intrathoracic pressure
“Puking”“Upchucking”“Throwing up”“tossing my cookies”
“Barfing”ASPAN Clinical Practice Guideline for Prevention &/or Management of PONV/PDNV 2010
Postoperative Nausea & Vomiting
• N&V that occurs within the first 24 hours following surgery– Early: 2-6 hours after surgery ( in PACU)– Late: 6-24 hour period– Delayed: Occurs beyond 24 hours in inpatient setting
• POSTDISCHARGE NAUSEA & VOMITING (PDNV)– Nausea & vomiting that occurs after discharge – Occurs beyond the initial 24 hours after DC
ASPAN Clinical Practice Guideline for Prevention &/or Management of PONV/PDNV 2010
Risk Factors for PONV
• Supported by Strong evidence– Female gender– History of PONV– History of motion sickness (Subjective)– Non-smoker– Postoperative use/administration of opioids– Use of volatile anesthetics– Use of Nitrous Oxide
• Supported by weak evidence– Age– Duration of surgery
• Supported by conflicting evidence– Type of surgeryASPAN Clinical Practice Guideline for Prevention &/or Management of PONV/PDNV 2010
Interventions
• Prophylaxic– Antiemetic strategies implemented PRIOR to onset of
symptoms– Anesthesia considerations: TIVA, NSAIDs, Regional blocks
• Pharmacological– Prescribed medications used to prevent &/or treat N&V– Dexamethasone– 5HT3 receptor antagonists– H1 receptor blockers (antihistamines– Scopolamine patch– Droperidol– New drug class: Neurokinin (NK1) antagonists
Interventions• Therapeutic:– Treatment options other than meds, requiring physicians
order, that are commonly used for management of PONV/PDNV
– Hydration– Pain management
• Complementary– Non-conventional treatment options used in conjunction
with traditional or conventional therapy in management of N&V
– Aromatherapy, Herbals, Acupressure
ASPAN Clinical Practice Guideline for Prevention &/or Management of PONV/PDNV 2010
Preadmission Testing/ Preop Holding
• Assess for PONV/PDNV risk factors• Document and communicate risk factor
assessment – identify prior to surgery• Prophylactic recommendation intervention based
on:– Efficacy of interventions• Consideration of success rate• Duration of action
– Risk of developing side effects, or number &/or severity of side effects
– CostASPAN Clinical Practice Guideline for Prevention &/or Management of PONV/PDNV 2010
PONV Prophylaxis Recommendation
• Prophylaxis for PONV:– Anesthesia considerations• Tiva, NSAIDs, Regional blocks
– Pharmacological• Dexametasone, 5HT3 receptor antagonists, H1
receptor blockers, Scopolamine patch, Droperidol, Neurokinin
– Therapeutic• Hydration (clear liquids 2 hours prior to surgery);
Supplemental IVs• Pain management: NSAIDs, Regional
– Complementary• P6 Acupoint stimulation
Postoperative Phase I/ II Management• Assess for postop N&V (High risk if opioid use)• If nausea present quantify severity• Implement rescue interventions– Verify adequate hydration and blood pressure– Select & administer appropriate rescue anti-emetic• 5-HT3 receptor antagonists, H1 receptor blockers,
Droperidol, Metoclopramide, low dose promethazine, prochloroperazine
– New drug class: Neurokinin antagonist– Consider aromatherapy
ASPAN Clinical Practice Guideline for Prevention &/or Management of PONV/PDNV 2010
Postdischarge N&V Recommentaions• Assess for PDNV risk factors• Administer prophylactic antiemetics in high risk– Dexamethasone, Scopolamine patch,
• Complementary interventions• Patient education on management• Rescue treatment– Antiemetic strategies implemented AFTER the onset of
symptoms • Rescue treatment for PDNV may include– Ondansetron dissolving tablets, Promethazine suppository or
tablets, Scopolamine patch
ASPAN Clinical Practice Guideline for Prevention &/or Management of PONV/PDNV 2010
NAUSEA & VOMITING
• PHYSIOLOGY– Neuromuscular interaction– Emetic Center• Vagal viscera• Sympathetic viscera• Vestibular• Cerebral Cortex/Limbic• Chemoreceptor Trigger Zone (CTZ)
Physiology of Vomiting: Neurotransmitters
Brunton LL. In: Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 1996;917-936.
Higher centers
Upper gastro-intestinal tract
Solitary tract
nucleus
Sensory input
Toxins in blood and
CSF
Cerebellum
Inner ear vestibular apparatus
Chemoreceptor trigger zone
Vomiting centerH M
S D M
S D M H
D S
M=Muscarinic cholinergic receptorsH = Histaminergic receptorsD = Dopaminergic receptorsS = Serotonergic receptors
NAUSEA & VOMITING
• RISK FACTORS–Anesthetic Agents–Hypotension–Variables in patients– Surgical Procedure–History–PAIN
ANTIEMETICS• Chlorpromazine (Thorazine)• Dimenhydrinate (Dramamine)• Meclizine (Antivert, Bonine)• Metoclopramide (Reglan)• Droperidol (Inapsine)• Hydroxyzine (Vistaril)• Diphenhydramine
(Benadryl)• Alcohol –aroma therapy• Quease ease – aroma therapy• Ephedrine
• Ondansetron HCL (Zofran)• Dolasetron (Anzemet)• Graniseton (Kytril) • Prochloperazine
(Compazine)• Promethazine
(Phenergan)• Trimethobenzamide HCL
(Tigan) • Transdermal Scope
Comparative Receptor Affinities of Antiemetic Drug Classes
Receptor Affinity Antiemetic Drug Class Dopamine ACH Histamine Seroton
Anticholinergic agent + ++++ +Antihistamines + ++ ++++Phenothiazines ++++ ++ ++++
Butyrophenones ++++ +
Benzamides +++ +
Selective Serotonin ++++ Antagonists
Ouellette SM. CRNA. 1999;10:24-33.
Postoperative Patient Management
• Expected Outcomes– Routine assessment– Appropriate PONV rescue treatment– Incidence of PONV will be reduced– Incidence of rescue will be reduced– Patient satisfaction will be improved– Time and cost of patient’s return to normal
activities will be reduced– Outpatient education and follow-up
QUESTIONS??