Postoperative Nausea and Vomiting
 
Definitions <ul><li>Vomiting :Forceful oral expulsion of gastric contents associated with contraction of abdominal and che...
The Facts <ul><li>Vomiting - unpleasant and medical risks : aspiration of gastric content; jeopardizes abdominal or ...
PONV: A Problem Adapted from Macario A et al. Anesth Analg . 1999;89:652–658. © 1999. With permission from Lippincott W...
Physiology of Nausea and Vomiting
Initiation of the Cascade <ul><li>Complex interaction of receptors, chemicals, and organ systems </li></ul><ul><li>Mediate...
Vomiting Center <ul><li>Composed of three nuclei </li></ul><ul><ul><li>The nucleus tractus solitarius (receives sensory in...
Key Neurotransmitters in the Brainstem Vomiting Center <ul><li>Opioid receptors are also located in the chemoreceptor tr...
Cascading information <ul><li>Information is transmitted to the vomiting center from several different areas through chemi...
First Signal <ul><li>Originates in CNS </li></ul><ul><li>Neurotransmitters responsible </li></ul><ul><ul><li>Acetylcholine...
Increasing Sensitivity <ul><li>Anesthetic agents and administered opioids increase the sensitivity of the vestibular cente...
2 nd Signal <ul><li>Gastrointestinal tract via vagus nerve </li></ul><ul><li>GI distention and manipulation leads to stim...
3 rd Signal <ul><li>Chemoreceptor trigger zone located on the floor of the fourth ventricle in the brain </li></ul><ul><l...
CTZ Zone
Mechanisms of CTZ <ul><li>Works through the 5-HT 3 receptors as well as dopamine type 2 receptors </li></ul><ul><li>D2 an...
Slowing down the Heart Rate…. <ul><li>With vomiting, the predominate branch of the autonomic nervous system becomes the pa...
Risk factors for post-operative nausea and vomiting in adults.
Patient-specific risk factors <ul><li>The most important being: </li></ul><ul><li>Female gender (RCT) </li></ul><ul><li>No...
Anaesthetic risk factors <ul><li>The most important being: </li></ul><ul><li>Use of volatile anaesthetics (RCT) </li></ul...
Surgical risk factors <ul><li>Duration of surgery (each 30-min increase in duration </li></ul><ul><li>increases PONV risk...
4 important risk factors <ul><ul><li>Female gender </li></ul></ul><ul><ul><li>Nonsmoking status </li></ul></ul><ul><ul><li...
Impact of Multiple Patient-Related Risk Factors* Risk of PONV Increased Based on Number of Primary Risk Factors Present ...
Options available
 
Evolution of Antiemetics for PONV 5-HT 3 =serotonin receptor type 3. 1950s 1960s 1970s 1980s 1990s 2000s Phenothiazines An...
Droperidol (Inaspine) <ul><li>Butyrophenone </li></ul><ul><li>Blocks dopamine-2 receptors in the CTZ and area postrema </l...
Metoclopramide (Reglan) <ul><li>Benzamide </li></ul><ul><li>Blocks dopamine-2 receptors in the CTZ and vomiting center </l...
Metoclompramide (Reglan) <ul><li>Usual adult dose for PONV: 25-50 mg IV </li></ul><ul><ul><li>10-20 mg IV for rescue N/V <...
Promethazine (Phenergan) <ul><li>Phenothiazine </li></ul><ul><li>Blocks dopamine-2 receptors in the CTZ and other areas of...
Diphenhydramine (Benadryl) <ul><li>Antihistamine </li></ul><ul><li>Suppresses motor-enhanced vestibular neuronal firing </...
Scopolamine <ul><li>Anticholinegic </li></ul><ul><li>Transdermal patch </li></ul><ul><li>Blocks the muscarinic-1 receptors...
Dexamethasone <ul><li>Corticosteroid </li></ul><ul><li>Antiemetic action not fully understood </li></ul><ul><li>Thought to...
NK1 Receptor Antagonist: Aprepitant <ul><li>Newest class of antiemetics </li></ul><ul><li>Antagonists at the neurokinin ty...
EMEND ® (aprepitant) Blocks Substance P From Binding to NK 1 Receptors EMEND Substance P NK 1 receptor 1. Keller M et a...
Supplemental Oxygen <ul><li>Attenuates the release of serotonin from the vagal afferent nerves in the GI tract by increasi...
Link between Laparoscopy and Oxygen <ul><li>Patients undergoing laparoscopy have reduced intestinal blood flow as a result...
Complementary Therapies: Acupuncture and Related Techniques <ul><li>Traditional Chinese medicine treated nausea and vomiti...
Complementary Therapies: Acupuncture and Related Techniques <ul><li>Nerve impulses produced by acupuncture also transmit t...
Complementary Therapies: Acupuncture and Related Techniques <ul><li>Acupressure </li></ul><ul><ul><li>Uses physical and me...
Complementary Therapies: Aromatherapy <ul><li>Dates back as far as 2800 BC </li></ul><ul><li>Herbal preparations and plant...
Complementary Therapies: Peppermint <ul><li>Remedy for morning sickness, dyspepsia, and other GI complaints </li></ul>
Inhalation of Isopropyl Alcohol Vapors <ul><li>Study of 100 healthy women undergoing outpatient gynecologic laparoscopic p...
Complementary Therapies: Oral Ginger <ul><li>Oral ginger has been used in China for treating GI symptoms such as nausea an...
Management of the problem
 
 
 
 
PONV Treatment Pathway - Mass. General Protocol for PONV <ul><li>Step 1. </li></ul><ul><li>Ondansetron 4 mg IV and dex...
 
 
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Ponv anaesthesia managment

Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Ponv anaesthesia managment

  • 1. Postoperative Nausea and Vomiting
  • 3. Definitions <ul><li>Vomiting :Forceful oral expulsion of gastric contents associated with contraction of abdominal and chest wall musculature. </li></ul><ul><li>Nausea: The unpleasant sensation of imminent need to vomit, usually referred to throat or epigastrium; a sensation that may or may not ultimately lead to the act of vomiting. </li></ul>
  • 4. The Facts <ul><li>Vomiting - unpleasant and medical risks : aspiration of gastric content; jeopardizes abdominal or inguinal closures; increased IV pressure: increase morbidity after ocular , tympanic , intracranial procedures ; elevate HR and BP: risk for MI and dysrhythmias ; gagging and retching: parasympathetic response: bradycardia and hypotension . </li></ul><ul><li>PONV increases </li></ul><ul><ul><ul><li>Time spent in recovery </li></ul></ul></ul><ul><ul><ul><li>Need for nurses </li></ul></ul></ul><ul><ul><ul><li>Need to admit overnight </li></ul></ul></ul><ul><li>This all leads to increased healthcare costs. </li></ul><ul><li>More than 25% of patients report experiencing PONV, with numbers reaching as high as 80% in high risk populations. </li></ul>
  • 5. PONV: A Problem Adapted from Macario A et al. Anesth Analg . 1999;89:652–658. © 1999. With permission from Lippincott Williams & Wilkins. Data from a survey of adult patients (N=101) conducted at Stanford University Medical Center. Patients were eligible if they were scheduled to undergo surgery at the center. Patients were asked to rank-order 10 possible postoperative outcomes from most to least desirable. F -test <0.01. Emesis is the postoperative outcome least preferred by patients Recall without pain 5 Residual weakness 6 Shivering 7 Sore throat 8 Somnolence 9 Incisional pain 3 Gagging on endotracheal tube 2 Nausea 4 Vomiting 1 Postoperative Outcomes Rank Postoperative Outcomes Least Preferred by Patients
  • 6. Physiology of Nausea and Vomiting
  • 7. Initiation of the Cascade <ul><li>Complex interaction of receptors, chemicals, and organ systems </li></ul><ul><li>Mediated though the vomiting center located in the dorsal area of the reticular formation of the medulla </li></ul>
  • 8. Vomiting Center <ul><li>Composed of three nuclei </li></ul><ul><ul><li>The nucleus tractus solitarius (receives sensory information from several afferent pathways) </li></ul></ul><ul><ul><li>The dorsal motor nucleus of the vagus </li></ul></ul><ul><ul><li>The nucleus ambiguus (primarily involved with the coordination of motor activity during the act of vomiting) </li></ul></ul><ul><li>5 primary afferent pathways </li></ul><ul><ul><li>Chemoreceptor triggering zone </li></ul></ul><ul><ul><li>Vagal mucosal pathway in GI system </li></ul></ul><ul><ul><li>Neuronal pathways from the vestibular system </li></ul></ul><ul><ul><li>Reflex afferent pathways from the cerebral cortex </li></ul></ul><ul><ul><li>Midbrain afferents </li></ul></ul>
  • 9. Key Neurotransmitters in the Brainstem Vomiting Center <ul><li>Opioid receptors are also located in the chemoreceptor trigger zone (CTZ); opioids are a risk factor for PONV. 1,5 </li></ul>Emetic Reflex Center 1–4 1. Nelson TP. J Perianesth Nurs . 2002;17:178–189. 4. Kovac AL. Drugs . 2000;59:213–243. 2. Cameron D, Gan TJ. Anesthesiol Clin North America . 2003;21:347–365. 5. Apfel CC et al. Anesthesiology . 1999;91:693–700. 3. Harrison S, Geppetti P. Int J Biochem Cell Biol . 2001;33:555–576. Substance P- NK 1 Receptor Serotonin- 5-HT 3 Receptor Acetylcholine- Muscarinic Receptor Cholinergic Receptor Dopamine- D 2 Receptor Histamine- H 1 Receptor
  • 10. Cascading information <ul><li>Information is transmitted to the vomiting center from several different areas through chemical stimulation of a variety of receptors </li></ul>
  • 11. First Signal <ul><li>Originates in CNS </li></ul><ul><li>Neurotransmitters responsible </li></ul><ul><ul><li>Acetylcholine </li></ul></ul><ul><ul><li>Histamine </li></ul></ul><ul><li>How to block transmission </li></ul><ul><ul><li>Anticholinergic agents that block binding of acetylcholine (scopolamine) </li></ul></ul><ul><ul><li>Diphendyramine (blocks the action of histamine) </li></ul></ul><ul><ul><li>Older drugs (promethazine and haloperidol) exact mechanism poorly understood </li></ul></ul>
  • 12. Increasing Sensitivity <ul><li>Anesthetic agents and administered opioids increase the sensitivity of the vestibular center </li></ul><ul><li>Rapid position change or movement of a sensitive patient may lead to the development of PONV </li></ul><ul><li>Position changes should be made slowly and patients should be instructed to keep their eyes closed during transport </li></ul>
  • 13. 2 nd Signal <ul><li>Gastrointestinal tract via vagus nerve </li></ul><ul><li>GI distention and manipulation leads to stimulation of mechanoreceptors in the wall of the gut and the release of serotonin </li></ul><ul><li>The administration of a selective serotonin antagonist at the 5-hydroxtryptamine 3 decreases the visceral information carried from the GI tract to the vomiting center </li></ul>
  • 14. 3 rd Signal <ul><li>Chemoreceptor trigger zone located on the floor of the fourth ventricle in the brain </li></ul><ul><li>Close association with cerebrospinal fluid </li></ul><ul><li>Large blood supply not protected by the blood brain barrier </li></ul><ul><li>Detects the presence of drugs or toxins </li></ul><ul><li>Culprit for severe nausea and vomiting associated with the administration of antineoplastic agents </li></ul>
  • 15. CTZ Zone
  • 16. Mechanisms of CTZ <ul><li>Works through the 5-HT 3 receptors as well as dopamine type 2 receptors </li></ul><ul><li>D2 antagonists (prochloroperazine, droperidol, and metoclopramide) </li></ul><ul><li>5-HT 3 antagonists (dolasetron, ondansetron, and granisetron) </li></ul>
  • 17. Slowing down the Heart Rate…. <ul><li>With vomiting, the predominate branch of the autonomic nervous system becomes the parasympathetic nervous system </li></ul><ul><ul><li>Hypotension and bradycardia may accompany retching </li></ul></ul>
  • 18. Risk factors for post-operative nausea and vomiting in adults.
  • 19. Patient-specific risk factors <ul><li>The most important being: </li></ul><ul><li>Female gender (RCT) </li></ul><ul><li>Non-smoking status (RCT) </li></ul><ul><li>History of PONV/motion sickness (RCT) </li></ul><ul><li>Less important being </li></ul><ul><li>- Age (adult) </li></ul><ul><li>- Predisposing gastric disorders </li></ul><ul><li>- Low threshold for nausea </li></ul><ul><li>- Preoperative anxiety </li></ul><ul><li>- Obesity (disputed in recent studies) </li></ul><ul><li>- Gastric distension (disputed in recent studies) </li></ul>
  • 20. Anaesthetic risk factors <ul><li>The most important being: </li></ul><ul><li>Use of volatile anaesthetics (RCT) </li></ul><ul><li>Nitrous oxide systematic review (SR) </li></ul><ul><li>Use of intra-operative (SR) and postoperative opioids (RCT) </li></ul><ul><li>Intubation. </li></ul>
  • 21. Surgical risk factors <ul><li>Duration of surgery (each 30-min increase in duration </li></ul><ul><li>increases PONV risk by 60%, so that a baseline risk </li></ul><ul><li>of 10% is increased by 16% after 30 min) (Prospective observational study) </li></ul><ul><li>Type of surgery (laparoscopy, laparotomy, breast, </li></ul><ul><li>strabismus, plastic surgery, maxillofacial, gynecological, abdominal, neurologic, ophthalmologic, urologic) (Prospective observational study) </li></ul><ul><li>Early oral intake </li></ul>
  • 22. 4 important risk factors <ul><ul><li>Female gender </li></ul></ul><ul><ul><li>Nonsmoking status </li></ul></ul><ul><ul><li>History of PONV or motion sickness </li></ul></ul><ul><ul><li>Use of postoperative opioids for the peri-operative care of surgical pain </li></ul></ul>
  • 23. Impact of Multiple Patient-Related Risk Factors* Risk of PONV Increased Based on Number of Primary Risk Factors Present * Validated in 2,722 adult patients receiving inhalational anesthesia. Apfel CC et al. Anesthesiology . 1999;91:693–700. Primary Risk Factors: History of PONV or motion sickness ■ Female sex ■ Nonsmoking ■ Use of postoperative opioids Patients With PONV, %
  • 24. Options available
  • 26. Evolution of Antiemetics for PONV 5-HT 3 =serotonin receptor type 3. 1950s 1960s 1970s 1980s 1990s 2000s Phenothiazines Antihistamines Butyropherones Substituted benzamides Anticholinergics 5-HT 3 receptor antagonists Substance P/NK 1 receptor antagonists
  • 27. Droperidol (Inaspine) <ul><li>Butyrophenone </li></ul><ul><li>Blocks dopamine-2 receptors in the CTZ and area postrema </li></ul><ul><li>Usual adult dose: 0.625-1.25 mg IV </li></ul><ul><li>Duration of action: up to 12-24 hours </li></ul><ul><li>Adverse effects: sedation, dizziness, anxiety, hypotension, extrapyramidal side effects </li></ul><ul><li>More effective for nausea than vomiting </li></ul><ul><li>FDA BLACK BOX WARNING 2001 </li></ul><ul><ul><li>Increased risk of lengthening of the QT intervals in some patients </li></ul></ul><ul><ul><li>Risk for cardiac patients!!! </li></ul></ul>
  • 28. Metoclopramide (Reglan) <ul><li>Benzamide </li></ul><ul><li>Blocks dopamine-2 receptors in the CTZ and vomiting center </li></ul><ul><li>Prokinetic properties that quicken esophageal clearance, enhance gastric emptying, and shorten bowel-transit time </li></ul><ul><li>Less effective than ondansetron or droperidol </li></ul><ul><li>Most commonly administered dose of 10 mg IV is not effective for prevention of PONV </li></ul>
  • 29. Metoclompramide (Reglan) <ul><li>Usual adult dose for PONV: 25-50 mg IV </li></ul><ul><ul><li>10-20 mg IV for rescue N/V </li></ul></ul><ul><li>Duration of action: up to 6 hours </li></ul><ul><li>Adverse effects: sedation, hypotension, extrapyramidal symptoms, restlessness </li></ul>
  • 30. Promethazine (Phenergan) <ul><li>Phenothiazine </li></ul><ul><li>Blocks dopamine-2 receptors in the CTZ and other areas of the brain </li></ul><ul><li>Also blcoks histamine-1 receptors and msucarinic-1 receptors </li></ul><ul><li>Usual adult dose: 6.25-12.5 mg IV </li></ul><ul><li>Duration of action: 4-6 hours </li></ul><ul><li>Adverse effects: sedation, hypotension, extrapyramidal symptoms </li></ul>
  • 31. Diphenhydramine (Benadryl) <ul><li>Antihistamine </li></ul><ul><li>Suppresses motor-enhanced vestibular neuronal firing </li></ul><ul><li>Adverse reactions: sedation, dry mouth, blurred vision, urinary retention </li></ul>
  • 32. Scopolamine <ul><li>Anticholinegic </li></ul><ul><li>Transdermal patch </li></ul><ul><li>Blocks the muscarinic-1 receptors in the cerebral cortex and pons and histamine-1 receptors in the hypothalamus and vomiting center to exert its antiemetic effects </li></ul><ul><li>Suppresses the noradrenergic system (improved adaptation to vestibular stimulation) </li></ul><ul><li>4 hour onset of action </li></ul><ul><ul><li>Needs to be placed the night before for patients with increased risk of PONV </li></ul></ul>
  • 33. Dexamethasone <ul><li>Corticosteroid </li></ul><ul><li>Antiemetic action not fully understood </li></ul><ul><li>Thought to work by </li></ul><ul><li>inhibition of prostaglandin syn. </li></ul><ul><ul><ul><li> tryptophan </li></ul></ul></ul><ul><ul><ul><li>release of endorphins </li></ul></ul></ul><ul><ul><ul><li>change in CSF opening pressure </li></ul></ul></ul><ul><ul><ul><li>+ psychological effects of steroids </li></ul></ul></ul><ul><li>ACUTE SIDE EFFECTS : flushing and perineal itching. </li></ul>
  • 34. NK1 Receptor Antagonist: Aprepitant <ul><li>Newest class of antiemetics </li></ul><ul><li>Antagonists at the neurokinin type-1 receptors </li></ul><ul><ul><li>Substance P is a neurokinin neurotransmitter that acts through neurokinin type-1 receptors found in the central and peripheral nervous system to induce nausea and vomiting </li></ul></ul><ul><li>FDA approved when used with standard antiemetics to prevent PONV in patients undergoing highly ematogenic chemotherapy </li></ul>
  • 35. EMEND ® (aprepitant) Blocks Substance P From Binding to NK 1 Receptors EMEND Substance P NK 1 receptor 1. Keller M et al. Biol Psychiatry . 2006;59:216–223. 2. Hargreaves R. J Clin Psychiatry . 2002;63(suppl 11):18–24. Binding of EMEND at the NK 1 Receptor Site 1,2
  • 36. Supplemental Oxygen <ul><li>Attenuates the release of serotonin from the vagal afferent nerves in the GI tract by increasing oxygen concentration to the tissues, thus enhancing delivery of oxygen to the intestine </li></ul><ul><li>GI tract has high metabolic demands and is intolerant to hypoxia or ischemia </li></ul>
  • 37. Link between Laparoscopy and Oxygen <ul><li>Patients undergoing laparoscopy have reduced intestinal blood flow as a result of insufflation of the abdomen </li></ul>
  • 38. Complementary Therapies: Acupuncture and Related Techniques <ul><li>Traditional Chinese medicine treated nausea and vomiting with acupuncture </li></ul><ul><li>Uses needles that are inserted into traditional acupuncture points in the body, initiating a series of physiological events that counter PONV </li></ul><ul><li>Certain nerve fibers are stimulated that result in nerve impulses being sent to the spinal cord </li></ul><ul><ul><li>Endorphogenic cells are stimulated to release endorphins </li></ul></ul>
  • 39. Complementary Therapies: Acupuncture and Related Techniques <ul><li>Nerve impulses produced by acupuncture also transmit to the periaqueductal gray area of the midbrain where enkephalin is released </li></ul><ul><ul><li>Causes a release of the monoamine neurotransmitters serotonin and norepinephrine in the spinal cord </li></ul></ul><ul><li>3 rd effect is release of beta-endorphins and adrenocorticotropic hormone (ACTH) from the pituitary gland into the bloodstream and cerebrospinal fluid </li></ul><ul><li>Calming of the GI tract </li></ul>
  • 40. Complementary Therapies: Acupuncture and Related Techniques <ul><li>Acupressure </li></ul><ul><ul><li>Uses physical and mechanical pressure instead of needles over the same meridians of the body </li></ul></ul>
  • 41. Complementary Therapies: Aromatherapy <ul><li>Dates back as far as 2800 BC </li></ul><ul><li>Herbal preparations and plant extracts </li></ul><ul><li>Use of oil of ginger as a prophylactic therapy </li></ul><ul><li>Isopropyl alcohol </li></ul><ul><li>Oil of peppermint </li></ul>
  • 42. Complementary Therapies: Peppermint <ul><li>Remedy for morning sickness, dyspepsia, and other GI complaints </li></ul>
  • 43. Inhalation of Isopropyl Alcohol Vapors <ul><li>Study of 100 healthy women undergoing outpatient gynecologic laparoscopic procedures </li></ul><ul><li>Randomly received 4 mg ondansetron or 70% isopropyl alcohol for postoperative nausea </li></ul><ul><li>Use of alcohol pads resulting in quicker relief of nausea </li></ul>
  • 44. Complementary Therapies: Oral Ginger <ul><li>Oral ginger has been used in China for treating GI symptoms such as nausea and vomiting </li></ul><ul><li>Ginger root, ginger powder, ginger candy, and ginger gum </li></ul><ul><li>Ginger oil in form of aromatherapy </li></ul><ul><li>Role not clearly defined by research </li></ul>
  • 45. Management of the problem
  • 50. PONV Treatment Pathway - Mass. General Protocol for PONV <ul><li>Step 1. </li></ul><ul><li>Ondansetron 4 mg IV and dexamethasone 4 mg IV as a single dose If nausea and vomiting continues to be problematic after 30 minutes, proceed to step 2: </li></ul><ul><li>Step 2. </li></ul><ul><li>Haloperidol 0.25mg IV or </li></ul><ul><li>Metoclopramide 20 mg IV. May be repeated x1 in 4 hours </li></ul><ul><li>If nausea and vomiting continues to be problematic after 30 minutes, proceed to step 3: </li></ul><ul><li>Step 3. </li></ul><ul><li>Promethazine 12.5 -25 mg IV q 4 h. or Meclizine 25mg orally q 8 h. or Prochlorperazine suppository 25 mg per rectum q 12 h. </li></ul><ul><li>If nausea and vomiting continues to be problematic, proceed to step 4: </li></ul><ul><li>Step 4. </li></ul><ul><li>Droperidol Prior to prescribing droperidol, physician must determine that pre-administration EKG QTc interval is < 440 msec [males] or <450 msec [females]. If within guidelines, then *Give droperidol 1.25 mg IV x 1 dose only *Patient's EKG must be monitored for 2-3 hr post-dose. </li></ul><ul><li>Note: These guidelines were developed by an interdisciplinary group of clinicians from the BWH and MGH Pharmacy and Anesthesia Departments. </li></ul><ul><li>http://www.massgeneral.org/pharmacy/Newsletters/2002/March%202002/Postoperative%20Nausea%20and%20Vomiting.htm </li></ul>

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