post operative nausea & vomitting · post operative nausea & vomiting a review of...
TRANSCRIPT
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.
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.