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Postoperative Nausea and Vomiting

Postoperative Nausea and Vomiting. Risk Factors and Prevention Plan. Cost. Postoperative nausea and vomiting incidence 25-30% Leads to poor patient satisfaction Delayed discharge Hospital admission Aspiration Disruption of suture lines. Risk Factors. Female Gender

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Postoperative Nausea and Vomiting

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  1. Postoperative Nausea and Vomiting Risk Factors and Prevention Plan

  2. Cost • Postoperative nausea and vomiting incidence 25-30% • Leads to poor patient satisfaction • Delayed discharge • Hospital admission • Aspiration • Disruption of suture lines

  3. Risk Factors • Female Gender • History of motion sickness or postoperative N/V • Pain • High levels of anxiety • Long surgical procedure • Type of surgery (intra-abdominal, gynecologic, laparoscopic, breast, ENT, strabismus) • Incidence of postoperative N/V • 0 risk factor -10% • 1 risk factor -20% • 2 risk factors -40% • 3 risk factors -60% • 4 risk factors -80%

  4. Prophylatic Agents • Dopamine receptor antagonists • Promethazine • long duration of action, may delay recovery from anesthesia • Droperidol • NNT 5-7 • excellent for nausea prophylaxis • FDA black box for QTc prolongation • Side effects: sedation, restlessness, hypotension, extrapyramidal

  5. Prophylatic Agents • Anticholinergic • Scopolamine • transdermal offers long duration of action, often used with opioid premedication • Side effects: sedation, dry mouth, dizziness, restlessness

  6. Prophylatic Agents • 5 HT3 receptor antagonists • Ondansetron, Dolasetron, Granisetron • NNT 5-6 • binds to chemoreceptor trigger zone and vagal afferents, specific • Effectiveness is similar for all three, difference is cost • Side effects: headache, constipation, elevated liver enzyme

  7. Prophylatic Agents • NK-1 receptor antagonist • Aprepitant • Better efficacy for vomiting vsondansetron up to 72 hours • Long duration of action

  8. Prophylatic Agents • Corticosteroids • Dexamethasone • Long duration of action • NNT for late postoperative N/V 4.3 • NNT for early postoperative N/V 7.1

  9. Postoperative N/V Prevention Strategy • 1-2 risk factors • 5HT3 antagonists • Dexamethasone • Scopolamine • Droperidol • 2-4 risk factors • Droperidol + 5HT3 antagonist • Dexamethasone + 5HT3 antagonist • Droperidol + dexamethazone • Greater than 4 risk factors • Combination antiemetics and IV anesthesia with propofol

  10. References • Habib, AS; Gan, TJ. What is the Best Strategy to Prevent Postoperative Nausea and Vomiting? Evidence-Based Practice of Anesthesiology. Chapter 40 • Van Erdewyk, JM. Postoperative Nausea and Vomiting. Anesthesia Review. Chapter 233

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