Download Post op Nausea and Vomiting PONV

Post Op Nausea and Vomiting
PONV
Issues That Keep Coming Up
Regina Hoefner-Notz MS,RN,CPAN, CPN
Clinical Manager Periop Services CHCO
ASPAN Regional Director: Region 1
Objectives
Appreciate patient concern and
anxiety associated with PONV
Understand the physiology of PONV
and treatment modalities
Identify the related issues of PONV
Increase awareness the most recent
guidelines created for PONV
Definitions
Postoperative Nausea and Vomiting:
PONV nausea and/or vomiting that occurs
within the first 24 hours after surgery
Early PONV: Occurs within the first 2-6 hours,
often in Phase I
Late PONV: Occurs in the 6-24 hour period
after surgery
Delayed PDNV: Occurs beyond the 24 hour
mark
POV: Reference to pediatric PONV since it is
frequently difficult for children to describe
nausea
Nausea
Subjective sensation in back of throat
Conscious cortical activity
May not result in vomiting
Vomiting
The forceful expulsion of the gastric
contents through the oral and/or
nasal cavity
Autonomic reflex directed by the
brainstem
Coordinated muscular movements
Physiological changes
Increase HR
Increased RR
Sweating
Retching
Objective attempt to vomit
Nonproductive
PONV : Patient Concerns
PONV is a huge concern to
patients
Patients rank it as the MOST
undesirable outcome of surgery,
more than pain.
Patients state that PONV is more
debilitating than post op pain.
PONV : Patient Concerns
The general incident of vomiting is
about 30%
The general incident of nausea is
about 50%
Subset of high risk patients is about
80%
Peters and Glass 2014
PONV : Financial Implications
Can prolong PACU stays
Can prolong Phase II stays
Can lead to unplanned admissions
PONV : Financial Implications
The cost of treating post op nausea
and vomiting in the US has been
estimated to cost several hundred
million dollars per year.
On average, patients with PONV will
cost an additional $451.00 per person
Cost of treating vomiting is 3x higher
then the cost of treating nausea
PONV : Who Does it Affect?
PONV affects about 1/3 of surgical
patients each year which is about 75
million patients.
PONV is one of the strongest
predictors of prolonged postoperative
stays and unanticipated admissions.
It is still greater then 40% for
outpatients that DO receive adequate
prophylaxis
PONV: Post Op Complications
Can lead to aspiration
Can lead to wound dehiscence
Can lead to bleeding
PONV: Post Op Complications
Can lead to dehydration and
electrolyte disturbances
Can increase ICP
Can lead to delay of normal
functioning
Initiating Vomiting
Complex Interaction of
Receptors,
Chemicals and
Organ systems
The Vomiting Center “controls” the act
of vomiting.
Numerous neuronal pathways converge
there to initiate the act of vomiting.
It is not a discreet anatomical site , but
rather, represents inter-related
neuronal networks.
Anatomical relationship between different parts of the
brain involved with nausea and vomiting.
Information travels to the vomiting center
through the CNS by the use of
neurotransmitters
Acetylcholine, Histamine, Serotonin,
and Dopamine receptors
Pathophysiological mechanisms
causing PONV or the manipulation
of neurotransmitters and receptors:
In the central nervous system (CNS)
In the brain stem
In the gastrointestinal tract (GI)
Inputs
Neuronal pathways from
Labyrinths
Higher centers of the cortex
Intracranial pressure receptors
Chemoreceptor Trigger Center (CTZ)
Vagal sensory pathways (GI Tract)
Labyrinth Vestibular
The vestibular apparatus in the
middle ear that responds to changes
in position of the patient.
Responsible for the nausea and
vomiting associated with balance
abnormalities.
Chemoreceptor Trigger Zone
The chemoreceptor trigger zone in the
medulla oblongata responds to
chemical changes in the
cerebrospinal fluid.
It responds to the peripheral nerve
pathways, which are stimulated by
chemical changes in the blood and
viscera.
Anatomical relationship between different parts of the
brain involved with nausea and vomiting.
Chemoreceptor Trigger Zone
(CTZ)
Close association with CSF and a
large blood supply.
Not protected by the blood brain
barrier.
Detects the presence of drugs and
toxins. (severe N&V)
CTZ works through the 5-HT3 and
Dopamine2 receptors
GI tract Stimulation via the Vagus Nerve
GI distention and manipulation can stimulate
receptors from the wall of the gut, which then
releases serotonin.
The presence of foreign chemicals or blood can also
release serotonin.
This calls for the
administration of a
selective serotonin
antagonist at the
5-hydroxytryptamine3
(5-HT3) receptor, such
as ondansetron.
Decreases the visceral information
carried from the GI tract to the
Vomiting Center.
PONV Guidelines
Last guidelines developed were from
2003 and 2007
Society for Ambulatory
Anesthesiology conducted literature
reviews yielding hundreds of
publications since 2007
Utilized a multidisciplinary approach
to re-evaluate this issue and
treatment
Goals of the Guidelines
Determine optimal dosage and timing
of antiemetic prophylaxis
Evaluate cost effectiveness strategies
Create an algorithm to identify
patients at risk and best treatment
options
Propose future research
P. Glass 2014
Goals of the Guidelines
Understand who is at risk for PONV in
adults and POV (children)
Establish factors that reduce the baseline
risks of PONV
Determine the most effective antiemetic
single/combo therapies pharmacological
and non-pharmacological
Determine the best approach to treatment
with or without prophylaxis
P. Glass 2014
Highest Indicators for PONV
Female gender
History of PONV
Non-smoking status
History of motion sickness
Use of opioids in PACU
Anesthesia predictors:
Uses of volatile agents
Duration of anesthesia
Identifying Patients at Risk
New information
Younger = significant risk (less than 50
yrs.)
Type of surgery: cholecystectomy,
gynecological, and laparoscopic surgery
associated with a higher risk of PONV
Intraoperative opioids has weak evidence
for causing increase PONV
Highest Indicators for POV in
Pediatrics
Surgery greater than 30 minutes
Age greater than 3 years
Strabismus surgery
History of POV
Relative with PONV
Age. Children are two
times more likely to
develop POV than
adults. POV is low in
very young children,
increases up to the age
of 5 and is highest in
children between the
ages of 6 and 16 years.
Low to No Evidence
BMI
Anxiety
Supplemental O2
Perioperative fasting
Migraines
Reduce Baseline Risks
The avoidance of general anesthesia
Preferential use of propofol infusions
Avoidance of Nitrous Oxide
Avoidance of volatile anesthetics
Minimize perioperative opioid usage
Adequate hydration
Reduce Baseline Risks
New information from review of
randomized controlled trials (RCT):
“supplemental oxygen had no effect
on nausea or vomiting”
This new guideline no longer
recommends supplemental O2 for
prevention of PONV
Orhan-Sungur, et all 2008
Reduce Baseline Risks
Pediatric patient respond to a decrease in
baseline risk factors
Utilizing blocks decreases opioid usage
Strabismus patient receiving peribulbar
blocks during repairs had decrease emesis
from control groups (Gupta et all 2007)
Utilizing propofol and dexamethasone
together decreases emesis in T&As (Erdem, et
all 2009)
Administer PONV Prophylaxis
Using 1&2 Interventions
Recommended PONV medications include:
5-hydroxytryptamines receptor antagonists (5-HT3)
Neurokinin-1 receptor antagonists (NK-1)
Corticosteroids
Butyrophenones
Antihistamines
Anticholinergics
Serotonin (5-HT3) Antagonists
Ondansetron (Zofran)
Granisetron (Kytril)
Tropisetron (Navoban)
Palonosetron 2nd generation 5-HT
Dolesteron (anzement)no longer marketed in
the US due to prolong QT and possible
torsades de pointe
No significant side effects. May cause HA,
dizziness or diarrhea.
Neurokinin-1 receptor antagonists
(NK-1)
Newly developed for severe nausea
and vomiting
Substance P belongs to the
neurokinin family of neurotransmitters
The medication, Aprepitant, blocks
this neurotransmitter
Oral administration
Works up to 24 hours
Corticosteroids
Dexamethasone (decadron)
Recommended to be given at the
beginning of induction for patients with
increase risk of PONV
Low risk, can be given at end of surgery
Can cause spikes in serum glucose. Use
cautiously with patients with labile blood
sugars
Can decrease use of overall opioid
medications/pain relief functionality
No definitive data on increasing risk of
postoperative infection
Dopamine (D2) receptor antagonist
Phenothiazine: Metoclopramide
(Reglan)
Butyrophenones: Droperidol
(Inapsine)
These drugs can cause prolonged
emergence, hypotension, or
extrapyramidal reactions.
Antihistamines
Promethazine (phenergan)
Diphenhydramine (benadryl)
Prochlorperazine (compazine)
Hydroxine (atarax)
Down side includes drowsiness, dry
mouth, possible dizziness, some
potentiate narcotics and barbiturates.
Anticholinergics
Scopolamine patch
Glycopyrrate (robinul)
Atropine
Dramamine
Sometimes more responsive to vestibular
impulses and motion sickness.
Anticholinergic agents will block the binding
of acetylcholine (ACh)
Alternative Measures ?
Aroma therapy: No significant evidenced
based data at this time
“QueaseEase” 4 essential oils
Spearmint, peppermint, ginger and lavender,
Deep Breathing :Maybe can’t hurt
Gastric Emptying: no information
Gastric Decompression: does not help
Some Acupressure bands: P6 studies
Management Algorithm:2014
Adult risk factors
Pediatric risk factors
Patient preference
Cost effectiveness
Reducing baseline risk
Low: wait and see
Medium: Pick 1-2 interventions
High: Greater than 2 interventions
“Just because its there doesn’t
mean you have to use it”
Need to identify the subset of patients that
might require prophylaxis
Generic drugs get the job done
Ondansetron 4mg, droperidol 1.25mg and
dexamethasone 4mg were equally effective
and independently reduced PONV risk by
25% (in adults)
Apfel et all, 2004
Risk Factor Assessment
Risk Level
Low Risk
Moderate
Risk
Severe
Risk
Very
Severe
% chance of
PONV
10-20%
40 %
60 %
80 %
# of prophylactic
interventions to
consider
0
1
2
3 or more
Rescue Treatment
• Antiemetic strategies
implemented AFTER the
onset of symptoms
• Administer different
medication then
prophylactic one
• Check for other reasons
such as hypotension
• ? isopropyl alcohol: not
effective prophylactic but
seems to help
afterwards
Nursing Considerations
Pre op Information
Thorough history
Risk factors
identified
Pre administration
of anti-emetics
Nursing Considerations
First and foremost - airway management,
preventing aspiration, providing high flow O2
Positioning- no sudden movements or transfers
Hydration- checking fluid deficits and rehydrating
appropriately.
Calming reassurance to decrease anxiety.
Deep breathing to optimize oxygenation.
Possible use of aroma therapy with inhalation of
isopropyl alcohol vapors.
Pain medication used judiciously, opioids verses
NSAID’s.
Medicate as necessary per MD order, evaluating
previous medications and their efficacy.
Patient Education
How to manage fluids
or foods
How many diapers or
how often child
urinated during the day
Should some
medications be taken
with food?
Comfort measures
specific for that child
When to call Primary
physician
The cost of treating
prolonged PONV
can be devastating
to the patient,
family and
institution.
Understanding
causality and
treatment options
are essential for
optimal post
operative care.
.