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TRANSCRIPT
Postop
erative Nausea &
Vom
iting
(PO
NV
) M
ND
AK
SPA
N Fall C
onferen
ceSaturday, Sep
tember 26
th, 2015K
im A
. Noble, P
h.D., R
N, C
PA
Nkanoble@
mail.w
idener.edu
Ob
jectives Follow
ing participation in this lecture, the participant will be able to:
•D
escribe anatom
y & p
hysiology of the Chem
oreceptor T
rigger Zone (C
TZ);
•A
pp
ly an un
derstandin
g of the chemical m
ediators involved in
vomitin
g to their p
harmacologic m
anagem
ent;
•A
pp
ly know
ledge of PO
NV
risk factors to the preven
tion an
d treatmen
t of PO
NV
;
Inciden
ce of PO
NV
/PD
NV
•R
emain
s a comm
on p
roblem
•E
stimated 20%
to 30% (G
A)
•H
igh Risk p
atients: 80%
•H
igh risk procedures
•E
metogen
ic anesthetics
•N
ausea 24 hours post discharge 35%
•P
DN
V 31%
(16% P
ON
V)
Gup
ta, et al (2004) An
esthesiology, 99, 488-495.
Chem
oreceptor T
rigger Zone (C
TZ): G
ross An
atomy
•B
rain Stem
:
•M
edulla Oblon
gata
•C
on
tribu
tors:
•C
entral n
ervous system (C
NS)
•G
I tract
•O
ther:
•B
lood borne stim
ulants/irritan
tshttp
://mbbsrevision
.blogspot.com
/2011/05/antiem
etics.html
CT
Z & V
omitin
g Cen
ter: A C
loser Look
•C
entral N
ervou
s System:
•IC
P
•C
erebral cortex [Sensory]
•C
erebellum [In
ner ear]
•P
eriph
eral Nervo
us System
:
•A
NS
•G
I tract:
•P
harynx
•B
lood borne stim
ulants/irritan
tshttp
s://usmle287.w
ordpress.com
/category/pharm
acology/page/2/
Pharm
acology: Overview
http://w
ww
.japtr.org/article.asp
?issn=2231-4040;year=2012;volum
e=3;issue=4;spage=202;ep
age=209;aulast=Bhan
dari
Pharm
acology: A C
loser Look
•C
NS:
•In
creased ICP
•C
ognition
•In
ner ear
•P
NS:
•G
I Tract
•C
TZ
http://w
ww
.pedson
cologyeducation.com
/PallC
areNon
Pain
SNausea.asp
Better Livin
g Through C
hemistry
•C
NS:
•C
ognition
•B
enzodiazep
ines
•In
ner ear
•H
istamin
e
•P
NS:
•G
I Tract
•M
uscarinic/C
holinergic
•D
opam
ine
•C
TZ
•5-H
T3 (Seroton
in)
•N
K-1 R
A (Substan
ce P)
Risk Factors P
ON
V/P
DN
V: O
verview
•R
isk factors for PO
NV
•P
atient-related risk factors
•Surgery-related risk factors
•A
nesthetic-related risk factors
•P
erioperative risk factors
http://w
ww
.medscap
e.org/viewarticle/548014
Step 1: Iden
tify Patien
ts at Risk
Risk
Factor
Po
ints
Female gen
der1 p
oint
Non
-smoker
1 poin
t
History of P
ON
V1 p
oint
Postop
erative opioids
1 poin
t
Sum0 to 4 p
oints
Ap
fel, et al (1999) Anesthesiology, 91, 693-700.
PO
NV
Prop
hylaxis
http://w
ww
.medscap
e.org/viewarticle/548014_2
Step 2: R
educe Baselin
e Risk Factors
•U
se regional an
esthesia
•U
se prop
ofol for induction
&
main
tenan
ce
•U
se intraop
erative supp
lemen
tal O2
•U
se hydration
•A
void nitrous oxide &
volatile gasses
•M
inim
ize opioid use
•M
inim
ize neostigm
ine use
Step 3: P
rophylaxis for M
oderate & H
igh Risk
•M
ultimodal drug p
rophylaxis:
•D
examethason
e 2.5 to 5 mg
•5-H
T3 [Seroton
in an
tagonists]
•O
ndan
setron 4m
g (adult)
•P
ediatrics 350 mcg/kg
•Scop
olamin
e Patch
•D
roperidol 0.625m
g to 1.25mg
•M
etoclopram
ide [D2 an
tagonist]
Step 4: A
ggressively Treat P
ON
V
•P
atients w
here prop
hylaxis was
ineffective or n
ot used:
•O
ndan
setron 4m
g first line
•A
dd additional agen
ts if PO
NV
p
ersists
•N
OT
E: If in
itial drug use was
ineffective, a secon
d dose of the sam
e drug is unlikely to be
effective and m
ay increase risk of
side effects.
Referen
ces