Post Operative

Nausea & Vomiting

A Review of Physiology and Current

Prophylaxis/Treatment Modalities

Matthew MacDonald, BSN, SRNA

York College of Pennsylvania/

Wellspan Health

9/17/16

Objectives

• Describe the physiologic processes

resulting in the phenomenon of PONV

• Identify causative factors of PONV

• Identify patient risk factors for PONV

• Identify antiemetic therapies and

describe the current prophylactic and

treatment modalities of PONV based on

current literature

“His bread in his belly shall be turned into the gall of asps

within him, The riches which he hath swallowed, he shall

vomit up, and God shall draw them out of his belly.” --Douhy-Rheims Bible, Job, 20: 14-15

https://www.rc.umd.edu/praxis/forgery/HTML/praxis.2011.haywood.html

https://www.healthtap.com/user_questions/6614681

http://www.riskmanagement365.com/tag/work-comp-2/page/6/

“The first trimester is a

period of rapid fetal growth,

and includes critically the

development of the CNS,

which is highly susceptible

to toxicosis.”

http://www.freepik.com/free-

vector/pregnant-woman-

outline_761518.htm

“PONV is mainly triggered by

perioperative administration of

emetogenic stimuli to

susceptible patients”

Apfel et al. 2012

http://www.apsf.org/newsletters/html/2012/spring/

04_shortage.htm

http://www.lifemartini.com/6-likely-symptoms-of-angina/

http://www.slideshare.net/kochikochi1/fluid-and-electrolytes-kochi-full

http://medical-dictionary.thefreedictionary.com/dehiscence https://www.cartoonstock.com/directory/m/mrsa.asp

What is PONV?

• Nausea – An unpleasant sensation that refers to an

inclination to vomit. From the Greek word “nautia”

meaning “seasickness”

• Vomiting – The forceful expulsion of GI contents from

the stomach through the mouth.

• Retching – An involuntary effort to vomit that does not

result in ejection of gastric contents

Diemunsch et al., 2009

What is PONV?

• “Any nausea, retching, or vomiting occurring during the first

24-48 h after surgery in inpatients.” Pierre 2012

• “A multifactorial phenomenon that can be triggered by

multiple receptor pathways at peripheral, central, or both

sites.” Apfel et al. 2012

• “Adverse reaction and physiologic response to the surgical

process represented by the expression of queasiness,

unsettled stomach, and urge to retch or vomit (nausea)

and/or the frank expulsion of gastric contents (vomiting)

occurring within 24 hours of surgery.”

Smith & Sahd 2016

Pathophysiology of PONV

Horn, 2008 http://www.sciencecartoonsplus.com/pages/gallery.php

Pathophysiology of PONV

Apfel, 2015

Pleuvry, 2009

Who’s at risk?

Gan et al., 2014

https://twitter.com/gbinfosec/status/714842080632246273

Patient-related risk factors

Apfel at al. 2012a

Anesthesia-related risk factors

Apfel et al., 2012a

Anesthesia-related risk factors

Sinclair et al. 1999

Surgery-related risk factors

Apfel et al., 2012a

https://www.andertoons.com/surgery/cartoon/6988/other-way-less-invasive-but-already-promised-the-interns

Pediatric risk factors

Risk Assessment Tools

Risk Assessment Tools

Apfel, 2015

Risk Assessment Tools

Apfel, 2015

PDNV

Apfel et al., 2012b

PDNV

Apfel et al., 2012b

PDNV

Apfel, 2015

PONV Management

Gan et al., 2014

PONV Risk Reduction

Gan et al., 2014

PONV Treatment

Gan et al., 2014

5-HT3 Antagonists

Ondansetron

• 4mg IV

• 8mg ODT

• 4hr plasma half-life

• No sedation/dry mouth

• QTc prolongation

Palonosetron

• 0.075mg IV every 24 hours

• 40hr plasma half-life

• More effective than

Ondansetron in PONV

prevention

• PDNV?

Golembiewski & Tokumaru, 2006

Muchatuta & Paech, 2009

Pleuvry, 2009

Corticosteroids

Dexamethasone

• 4-5mg IV effective dose

• Slow onset of action

• Give at beginning of surgery

• Efficacy similar to Ondansetron and Droperidol

• Improved quality of recovery

• Relatively contraindicated in labile Diabetics

Apfel et al. 2004

Cruthirds et al. ,2013

Gan et. al, 2014

Golembiewski & Tokumaru, 2006

Pierre & Whelan, 2012

D2 Antagonists

(Butyrophenones)

Droperidol

• FDA black box warning in 2001

• QTc prolongation and Torsades

• Still utilized in 19 of 24 European countries

Haloperidol

• 0.5-2mg IV (1mg IV)

• QTc prolongation risk on label

• No difference in PONV rate btwn.. 1mg

Haldol and 4mg Zofran IV or 0.625mg

Droperidol

Cruthirds et al., 2013 Gan et al., 2014

Pleuvry, 2009

Pierre & Whelan, 2013

H1 Antagonists

Benadryl

• 25-50mg IV

• Suppress motion-enhanced vestibular neuronal firing

• Sedation, dry mouth, blurred vision, dizziness, and

urinary retention

Gan et al., 2014

Pleuvry, 2009

M1 Antagonists

Scopolamine

• Blocks M1 receptors in the cortex and pons along with H1

receptors in the hypothalamus and vomiting center.

• Also shown to suppress the noradrenergic system

giving way to improved adaptation to vestibular

stimulation.

• TD patch can provide PONV relief for up to 72 hours

• 4 hour onset of action – Bolus layer!

• Visual disturbances btwn.. 24 and 48 hours of

application

Cruthirds et al., 2013

Gan et al., 2014

Golembiewski & Tokumaru, 2006

Pierre & Whelan, 2012

NK1 Antagonists

Aprepitant

• Neurokinin type-1 receptor antagonist

• Significantly more effective than

Ondansetron in emesis prevention at 24

and 48 hours post-op as well as nausea

severity reduction in the first 48 hours

post-op

• 40mg PO most effective dose given

preoperatively

• No major adverse effects have been

observed

Diemunsch et al., 2009

Milnes et al., 2015

Who to treat?

Targeted Multi-modal Prophylaxis

Apfel et al. 2004

Combination Therapy

Gan et al. 2014

Apfel, 2015

Current Practice at YH

http://csmit526.wixsite.com/casmith Apfel, 2015

Gan et al., 2014

https://thefourthplane.com/

Most Recent PONV Textbook

http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781316135853

References

• Apfel, C.C. (2015). Postoperative Nausea and Vomiting. In R. Miller (Ed.), Miller’s

Anesthesia 8th ed. (pp. 2947-2973). Philadelphia, PA: Elsevier Saunders.

• Apfel, C.C., Heidrich, F.M., Jukar-Rao, S., Jalota, L., Hornuss, C., Whelan, R.P.,...

Cakmakkaya, O.S. (2012a). Evidence-based analysis of risk factors for

postoperative nausea and vomiting. British Journal of Anaesthesia, 5, 742-53.

doi:10.1093/bja/ aes276

• Apfel, C.C., Korttila, K., Abdalla, M., Kerger, H., Turan, A., Vedder, I.,…Roewer, N. (2004).

A factorial trial of six interventions for the prevention of postoperative nausea and

vomiting. The New Endland Journal of Medicine, 350(24), 2441-2451.

• Apfel, C.C., Laara, E., Koivuranta, M., Grein, C.A., Roewer, N. (1999). A simplified risk

score for predicting postoperative nausea and vomiting. Anesthesiology, 91,

693-700.

• Apfel, C.C., Philip, B.K., Cakmakkaya, O.S., Shilling, A., Shi, Y.Y., Leslie, J.B.,…Kovac, A.

(2012b). Who is at risk for postdischarge nausea and vomiting after ambulatory

surgery? Anesthesiology, 117(3), 475-485.

• Cruthirds, D., Sims, P.J., Louis, P.J. (2013). Review and recommenations for the

prevention, management, and treatment of postoperative and postdischarge nausea

and vomiting. Oral and Maxillofacial Surgery, 115(5), 601-610.

• Diemunsch, P., Joshi, G.P., Brichant, J.F. (2009). Neurokinin-1 receptor antagonists in the

prevention of postoperative nausea and vomiting. British Journal of Anaesthesia,

103(1) 7-13.

References

• Gan, T.J., Diemunsch, P., Habib, A.S., Kovac, A., Kranke, P., Meyer, T.A.,…Tramer, M.R.

(2014). Consensus guidelines for the management of postoperative nausea and

vomiting. Anesthesia & Analgesia, 118(1), 85-113.

• Golembiewski, J., Tokumaru, S. (2006). Pharmacological prophylaxis and management of

adult postoperative/postdischarge nausea and vomiting. Journal of Perianesthesia

Nursing, 21(6), 385-397.

• Grunberg, S.M., Hesketh, P.J. (1993). Control of chemotherapy-induced emesis. The New

England Journal of Medicine, 329(24), 1790-1796.

• Habib, A.S., White, W.D., Eubanks, S., Pappas, T.N., Gan, T.J. (2004). A randomized

comparison of a multimodal management strategy versus combination antiemetics for

the prevention of postoperative nausea and vomiting. Anesthesia & Analgesia, 99,

77-81.

• Hocking, G., Weightman, W.M., Smith, C., Gibbs, N.M., Sherrard, K. (2013). Measuring the

quality of anaesthesia from a patient’s perspective: development, validation, and

implementation of a short questionnaire. British Journal of Anaesthesia 111(6), 979-

989. doi:10.1093/bja/aet284

• Horn, C.C. (2008). Why is the neurobiology of nausea and vomiting so important?

Appetite, 50, 430-434.

• Koch, K.L.S.R.M. (2010). Nausea. Retrieved from http://ww.ebrary.com

• Macario, A., Weinger, M., Carney, S., Kim, A. (1999). Which clinical anesthesia

outcomes are important to avoid? The perspective of patients. Anesthesia &

Analgesia, 89, 652-658.

http://ww.ebrary.com

References

• Milnes, V., Gonzalez, A., Amos, V. (2015). Aprepitant: A new modality for the prevention of

postoperative nausea and vomiting: An evidence-based review. Journal of

PeriAnesthesia Nursing, 30(5), 406-417.

• Muchatuta, N.A., Paech, M.J. (2009). Management of postoperative nausea and

vomiting: focus on palonosetron. Therapeutics and Clinical Risk Management, 5, 21-

34.

• Pierre, S., Whelan, R. (2013). Nausea and vomiting after surgery. British Journal of

Anaesthesia, 13(1), 28-32.

• Pleuvry, B.J. (2009). Physiology and pharmacology of nausea and vomiting. Anaesthesia

and Intensive Care Medicine, 10(12), 597-600.

• Sanger, G.J., Andrews, P.L.R. (2006). Treatment of nausea and vomiting: Gaps in our

knowledge. Autonomic Neuroscience: Basic and Clinical, 129, 3-16.

• Sinclair, D., Chung, F., Mezei, G. (1999). Can postoperative nausea and vomiting be

predicted? Anesthesiology, 91, 109-118.

• Smith, C.A., Ruth-Sahd, L. (2016). Reducing the incidence of postoperative nausea and

vomiting begins with risk screening: An evaluation of the evidence. Journal of

Perianesthesia Nursing, 31(2), 158-171.

• Van den Bosch, J.E., Kalkman, C.J., Vergouwe, Y., Van Klei, W.A., Bonsel, G.J.,

Grobbee, D.E., Moons, K.G.M. (2005). Assessing the applicability of scoring systems

for predicting postoperative nausea and vomiting. Anasthesia, 60, 323-331.