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PONV Guidelines

PONV Guidelines

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Published by: damondouglas on Nov 10, 2008
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University of Maryland Medical Center 
Postoperative Nausea and Vomiting GuidelinesRationale
Postoperative nausea and vomiting (PONV) are frequent complications of surgeryand anesthesia. Currently the overall incidence of postoperative nausea and vomiting isestimated to be 25-30%.
PONV can lead to delayed postanesthesia care unit recoveryroom discharge, prolonged hospitalization, decreased patient satisfaction and increaseduse of resources. However, given that only 25-30% of patients actually experiencesPONV, routine prophylaxis for PONV is not indicated.The decision to use antiemetic prophylaxis should be based upon risk factors for nausea and vomiting and the potential for serious sequelae from vomiting.
A systematic search of a medical literature database (http://www.ncbi.nih.gov/entrez/query.fcgi) revealed several studies on PONV and risk models. Risk models thatwere identified and evaluated include Apfel et al, Gan et al, and Sinclair et al.
Inaddition, a comparative study of six models, including those previously identified wasevaluated. Furthermore, a query to the United Health System Consortium listserv elicitedseveral strategies for the control of postoperative nausea and vomiting. The University of Kentucky has also developed guidelines for the use of postoperative nausea andvomiting. However, these guidelines were created prior to the FDA black box warningfor droperidol.
Risk Factors for PONV
The risk factors associated with postoperative nausea and vomiting can beclassified as patient or operative.
 The risk of PONV is higher in adults than in children, in women than in men, inobese patients, in patients who have high preoperative anxiety, and in patients with ahistory of PONV or motion sickness.The type of operative procedure can increase the rate of postoperative nausea andvomiting, such as intra-abdominal, major gynecological, orthopedic, ear-nose-throat,laparoscopic surgery, adenotonsil-lectomy, and surgery for strasbismus. Intubation mayalso cause nausea and vomiting.
Three 5HT3 receptor antagonists have been studied for use in patients for  prevention of postoperative nausea and vomiting. Placebo-controlled trials havedemonstrated efficacy with ondansetron, dolasetron and granisetron.Ondansetron can be given as a 4 mg single IV dose at the induction of anesthesia.In two trials comparing ondansetron 4 mg IV the percentage of patients with no emeticepisodes were 76% and 63%, respectively. Both studies showed greater response than inthe placebo group.A pooled analysis of three trials determined that 12.5 mg of dolasetron given IVwas effective in the prevention of postoperative nausea and vomiting. Dolasetron 12.5mg, 25 mg, 50 mg, and 100 mg dolasetron doses were assessed for efficacy when given
near the end of anesthesia. Efficacy was measured as no emetic episodes and no rescuemedications. Complete response rates were 55%, 55%, 57% and 58% for the 12.5 mg, 25mg, 50 mg and 100 mg doses, respectively. All four doses were statistically greater than placebo; however, there was no statistical difference between the dolasetron doses. Thus,dolasetron 12.5 mg IV was the lowest maximally effective dose.Granisetron has also been studied for its role in the prevention of nausea andvomiting in postoperative patients. In one study 868 patients were assessed for emeticcontrol. Of these patients, 63% had no episodes of vomiting within the first 24 hours.Each of these agents is effective in the prevention of nausea and vomiting.Patients who do fail prophylactic therapy do not appear to benefit from repeat doses of the same antiemetic. In a study by Kovac et al, patients were monitored for nausea before prophylactic ondansetron dosing, at 10, 20, 30, 60 and 120 minutes followingrandomized dosing, at PACU discharge, and 22 hours following PACU discharge.Complete response to repeat ondansetron doses (during the two-hour period followinganesthesia) versus placebo was not significantly different.
The authors also noticed thatthe patients who did not respond to the original ondansetron prophylactic dose appear less likely to respond to another dose in the same drug class. As the etiology of  postoperative nausea and vomiting is multifactorial, a combination of drugs fromdifferent classes for the treatment may be necessary.For patients who received no prophylactic dose or failed to respond to prophylactic 5HT3 receptor antagonists, traditional antiemetics are appropriate treatmentoptions. These antiemetics include metoclopramide 10 mg, prochlorperazine 2.5-10 mg,and promethazine 12.5 mg.
Based on the literature the following key points can be made
Approximately 30% of surgery patients will experience nausea/vomiting
Patient risk factors can be used to determine patients at risk for PONV
Patients who do not respond to initial 5HT3 prophylaxis require treatment with adifferent class of drug
Guidelines for the use of antiemetics for postoperative nausea and vomiting basedon these principles are shown below.Indications
Patients who receive 5HT3 receptor antagonists for the prevention of postoperativenausea and vomiting (PONV) must meet the following criteria:1.Prior history of postoperative nausea and vomiting or motion sickness.2.Patient is undergoing a procedure associated with high rates of postoperative nauseaand vomiting (laparotomy, ENT, or gynecologic).3.Patient is receiving highly emetogenic medications.

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