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POST OPERATIVE
NAUSEA AND
VOMITING
Robert Ferrante
Pharmacy Candidate
Objectives
• Discuss the prevalence of Post Operative Nausea and
Vomiting (PONV) and why reducing PONV is so important
to hospitals
• Review the evolution of PONV treatment
• Examine the current medications used for PONV
Post Operative Nausea and Vomiting
(PONV)1
• Up to 35% of ambulatory patients affected
• 70% of high risk patients
• Number one concern of patients
• … above pain, death, and MI
• Patients often classified by risk
Risk Factors
• Younger
• Female
• “Large body habitus”
• History of:
• PONV
• Motion Sickness
• Anxiety
• Procedures:
• Head/Neck
• Intraabdominal
• Larparoscopic
• Gynecologic
• Medications:
• Opiods
Why So Important?
• Medical Consequences
• Patient satisfaction
• Shorter PACU stays
• More patients
• MORE MONEY
• Mo’ Problems?
http://www.frca.co.uk/article.aspx?articleid=354#faq
Antiemetics
https://www.inkling.com/read/pharmacology-brenner-stevens-
Droperidol3
• Potent D2 Receptor antagonist
• PONV: 0.625-1.25 mg IM/IV Q3-4h
• Adjust for renal, hepatic, and age-related factors.
• 75% renal elimination
• Extensive liver metabolism
• T ½ - 135 mins
Droperidol Brief History1,2,3
• Droperidol was the foundation for PONV
• Effective and inexpensive
• December 2001: FDA issue BBW
• Arrhythmic-Effects
• Heavily disputed.
• Should be reserved for resistant patients
• Requires excessive monitoring
• ECG
• Cost increase
Droperidol3
• Contraindications
• First line treatment for anything but PONV
• Known or suspected QT interval
• Major drug interactions
• Drugs that may cause QT prolongation
• Including antiarrhythmics, opiods antipsychotics, and, diuretics
Reglan (Metoclopramide)4
• MOA:
• Peripheral dopamine receptor inhibiton
• Sensitizes tissues to acetylcholine (does not stimulate).
• Postoperative nausea and vomiting: 10 to 20 mg IV/IM
every 4 to 6 hours as needed
• CrCl < 40mL/min: 50% dose
• Geriatric: Initiate at 50% dose
• Adverse Effects:
• Asthenia
• Headache, Fatigue, Somnolence
• N/V
Reglan (Metoclopramide)
• BBW – Tardive dyskinesia
• Contraindications:
• Concomitant use with drugs likely to cause extrapyramidal
reactions
• Epilepsy
• Gastrointestinal hemorrhage, mechanical obstruction, or
perforation.
• REMS program required for other Indications
Reglan Efficacy5
• Metoclopramide vs Ondansetron
• According to a meta-analysis of 54 studies, metoclopramide is as
effective as ondansetron in preventing postoperative nausea (59%
vs 48%, respectively; p = 0.125)
• Metoclopramide prevented postoperative vomiting in only 35% of
patients compared with 50% of those using ondansetron (p <
0.001)
• Metoclopramide vs Droperidol
• Metoclopramide was inferior to droperidol in preventing both
postoperative nausea and vomiting.
• The incidence of nausea was 41% for droperidol and 52% for
metoclopramide (p < 0.008);
• The incidence of vomiting was 26% for droperidol versus 34% for
metoclopramide (p < 0.001)
Aloxi (Palonosetron)6
• PONV; Prophylaxis: 0.075 mg IV as a single dose
immediately before induction of anesthesia Major side
effects
• No Dose adjustments!
• Contraindications?... Not really
• Pregnancy Category B
• Major drug interactions?... Not really…
• Apomorphine
Aloxi (Palonosetron)
• Adverse Effects:
• Bradyarrhythmia (1-4%)
• Constipation (5%)
• Headache (9%)
• One vial = about $400
Aloxi Vs. Ondansetron7
• A Randomized, Double-blind Trial of Palonosetron
Compared with Ondansetron in Preventing Postoperative
Nausea and Vomiting after Gynaecological Laparoscopic
Surgery.
• Study design:
• Induced with propofol
• Intubated with rocuronium
• NM blockade reversed with pyridostigmine and glycopyrolate
Aloxi Vs. Ondansetron7
• 0.075 mg Palonosetron , n = 45
• 8 mg Ondansetron, n = 45
• Results:
• Over 24 hours, overall PONV in 30 ondansetron patients, 19 in
palonosetron
• Rescue antiemetics were used in an equal number of patients
• Adverse Events:
• Headache, Dizziness, Constipation, Myalgia
• Basically the same
• Patient Satisfaction:
• 21 in ondansetron
• 30 in palonosetron
References
• 1.) Ting, P. Post-operative Nausea and Vomiting (PONV): An Overview. Available
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from http://anesthesiologyinfo.com/articles/04252004.php
2.) Brenner GM, Stevens CW. Pharmacology. 4th Edition. Tulsa, OK. 2013
3.) Cherry W. Jackson, Amy Heck Sheehan, Jennifer G. Reddan. Evidence-Based
Review of the Black-box Warning for Droperidol. Am J Health Syst
Pharm. 2007;64(11):1174-1186.
4.) Metoclopramide. In: DRUGDEX Evaluations [database on the
Internet]. Greenwood Village (CO): Thompson Micromedex; 1974-2014 [cited 18
Sep 2014].
5.) Domino KB, Anderson EA, Polissar NL, Posner KL. Comparative efficacy and
safety of ondansetron, droperidol, and metoclopramide for preventing
postoperative nausea and vomiting: a meta-analysis. Anesth Analg 1999;88:13709.
6.) Palonosetron. In: DRUGDEX Evaluations [database on the
Internet]. Greenwood Village (CO): Thompson Micromedex; 1974-2014 [cited 18
Sep 2014].
7.)Park SK, Cho EJ. A Randomized, Double-blind Trial of Palonsetron Compared
with Ondansetron in Preventing Postoperative Nausea and Vomiting after
Gynaecological Lapaoscopic Surgery. J Int Med Res. 2011 39: 399
Questions?