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??