Postop

erative Nausea &

Vom

iting

(PO

NV

) M

ND

AK

SPA

N Fall C

onferen

ceSaturday, Sep

tember 26

th, 2015K

im A

. Noble, P

h.D., R

N, C

PA

Nkanoble@

mail.w

idener.edu

Ob

jectives Follow

ing participation in this lecture, the participant will be able to:

•D

escribe anatom

y & p

hysiology of the Chem

oreceptor T

rigger Zone (C

TZ);

•A

pp

ly an un

derstandin

g of the chemical m

ediators involved in

vomitin

g to their p

harmacologic m

anagem

ent;

•A

pp

ly know

ledge of PO

NV

risk factors to the preven

tion an

d treatmen

t of PO

NV

;

Inciden

ce of PO

NV

/PD

NV

•R

emain

s a comm

on p

roblem

•E

stimated 20%

to 30% (G

A)

•H

igh Risk p

atients: 80%

•H

igh risk procedures

•E

metogen

ic anesthetics

•N

ausea 24 hours post discharge 35%

•P

DN

V 31%

(16% P

ON

V)

Gup

ta, et al (2004) An

esthesiology, 99, 488-495.

Chem

oreceptor T

rigger Zone (C

TZ): G

ross An

atomy

•B

rain Stem

:

•M

edulla Oblon

gata

•C

on

tribu

tors:

•C

entral n

ervous system (C

NS)

•G

I tract

•O

ther:

•B

lood borne stim

ulants/irritan

tshttp

://mbbsrevision

.blogspot.com

/2011/05/antiem

etics.html

CT

Z & V

omitin

g Cen

ter: A C

loser Look

•C

entral N

ervou

s System:

•IC

P

•C

erebral cortex [Sensory]

•C

erebellum [In

ner ear]

•P

eriph

eral Nervo

us System

:

•A

NS

•G

I tract:

•P

harynx

•B

lood borne stim

ulants/irritan

tshttp

s://usmle287.w

ordpress.com

/category/pharm

acology/page/2/

Pharm

acology: Overview

http://w

ww

.japtr.org/article.asp

?issn=2231-4040;year=2012;volum

e=3;issue=4;spage=202;ep

age=209;aulast=Bhan

dari

Pharm

acology: A C

loser Look

•C

NS:

•In

creased ICP

•C

ognition

•In

ner ear

•P

NS:

•G

I Tract

•C

TZ

http://w

ww

.pedson

cologyeducation.com

/PallC

areNon

Pain

SNausea.asp

Better Livin

g Through C

hemistry

•C

NS:

•C

ognition

•B

enzodiazep

ines

•In

ner ear

•H

istamin

e

•P

NS:

•G

I Tract

•M

uscarinic/C

holinergic

•D

opam

ine

•C

TZ

•5-H

T3 (Seroton

in)

•N

K-1 R

A (Substan

ce P)

Risk Factors P

ON

V/P

DN

V: O

verview

•R

isk factors for PO

NV

•P

atient-related risk factors

•Surgery-related risk factors

•A

nesthetic-related risk factors

•P

erioperative risk factors

http://w

ww

.medscap

e.org/viewarticle/548014

Step 1: Iden

tify Patien

ts at Risk

Risk

Factor

Po

ints

Female gen

der1 p

oint

Non

-smoker

1 poin

t

History of P

ON

V1 p

oint

Postop

erative opioids

1 poin

t

Sum0 to 4 p

oints

Ap

fel, et al (1999) Anesthesiology, 91, 693-700.

PO

NV

Prop

hylaxis

http://w

ww

.medscap

e.org/viewarticle/548014_2

Step 2: R

educe Baselin

e Risk Factors

•U

se regional an

esthesia

•U

se prop

ofol for induction

&

main

tenan

ce

•U

se intraop

erative supp

lemen

tal O2

•U

se hydration

•A

void nitrous oxide &

volatile gasses

•M

inim

ize opioid use

•M

inim

ize neostigm

ine use

Step 3: P

rophylaxis for M

oderate & H

igh Risk

•M

ultimodal drug p

rophylaxis:

•D

examethason

e 2.5 to 5 mg

•5-H

T3 [Seroton

in an

tagonists]

•O

ndan

setron 4m

g (adult)

•P

ediatrics 350 mcg/kg

•Scop

olamin

e Patch

•D

roperidol 0.625m

g to 1.25mg

•M

etoclopram

ide [D2 an

tagonist]

Step 4: A

ggressively Treat P

ON

V

•P

atients w

here prop

hylaxis was

ineffective or n

ot used:

•O

ndan

setron 4m

g first line

•A

dd additional agen

ts if PO

NV

p

ersists

•N

OT

E: If in

itial drug use was

ineffective, a secon

d dose of the sam

e drug is unlikely to be

effective and m

ay increase risk of

side effects.

Referen

ces