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
Definitions
NAUSEA
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 surgery
ASPAN 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
– Cost
ASPAN 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
Sensory
input
Higher
centers
Cerebellum
HM
Solitary
tract
nucleus
SDMH
M=Muscarinic cholinergic receptors
H = Histaminergic receptors
D = Dopaminergic receptors
S = Serotonergic receptors
Vomiting center
SDM
Chemoreceptor trigger
zone
DS
Upper gastrointestinal tract
Inner ear
vestibular
apparatus
Toxins in
blood and
CSF
Brunton LL. In: Goodman and Gilman’s The Pharmacological Basis of Therapeutics.
1996;917-936.
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
Anticholinergic agent
+
ACH
Histamine Seroton
++++
+
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??