post operative nausea & vomiting dr.m.kannan md da professor and hod department of...

Post Operative Nausea &Vomiting

Dr.M.Kannan MD DAProfessor And HODDepartment of

AnaesthesiologyTirunelveli Medical College

Post Operative Nausea &Vomiting

Regurgitation

• Passive process

Lower Oesophageal Sphincter

• Oesophageal Smooth muscle-intrinsic sphincter

• Crural fibers of the Diaphragm –extrinsic sphincter

• Oblique fibres of the Stomach

Gastric Emptying

• Gastric Emptying Time Adult- 5 to 6 hours

• Prolonged –Solid food,Fats

• Reduced- Liquid food• Peadiatric –time-4h• Infant-3h

• New Born-2h

Factors Associated with PONV

• Patient Factor

• Surgical Factor

• Anaesthetic Factor

Patient Factor -PONV

• Children• Women• Full Stomach• Hiatus Hernia• Gastric outlet

Obstruction

Surgical Factor-PONV

• Type of Surgery

-Gynaecological

-ENT

-Squint Surgery

-Gastrointestinal• Duration of Surgery• Antibiotics

Anaesthetic Factor-PNOV

• Opiods• Volatile Agents• Postoperative Pain• Hypotension –

Spinal/Epidural• Experience of

Anaesthesiologist

Adverse Effect of PONV

• Patient Distress• Aspiration of Stomach

content• Poor Surgical Outcome ?• Intra cranial pressure• Intraocular pressure• Intra thoracic pressure• Intra abdominal pressure• Violent peristalsis

• Neurosursery• Opthalmic surgery• Head & Neck surgery• Abdominal wound• Oesophageal Surgery

Mendelsons Syndrome

• Aspiration Pneumonities

• Pathophysiological Canges

-Atelectasis

-Alveolar Oedema

-Loss of Surfactant

-Pulmonary Oedema

Pathophysiological Changes

• Intrapulmonry Shunting

• Hypoxia• Hypocapnia• Hypercapnia• Pulmonary

Hypertesion

Symptoms

• In drawing of intercostal space

• Wheezing

• Tachycardia

• Tachypnia

Prevention

• Head down Position &Neck turned to one side

Prevention

• Fasting

• Empty the Stomach

• Reduce the volume –Metclopramide

• Reduce the acidity-Sodium Citrate

-H2blockers-Ranitidine

Central acting -Ondesetron

• Acts on Dopamine receptor –Stomach&CTZ

• Gastric emptying time

• Lower Oesophageal tone

• Dose 10mg IV or IM

• Effect 1-3min

Metclopramide

Ranitidine

• H2 Receptor antogonist

• Reduces Acidity

• Dose 50mg IV-1-2hours

Ondansetron

• 5 HT3 Receptor Antagonist

• Stomach& CNS

• Dose 4 mg IV-10 -15 min

Prevention

• Suction of the Pharyngeal content

Prevention-Regurgitation

• Sellicks Maneuver

Sellicks Maneuver

Intubation

Rapid-Sequence Induction

• Tendelenberg Position –Suction Apparatus• Pre-Oxygenate 3-5Min• Prior curarization• Sellicks maneuver• Thiopentone IV• Succinylcholine IV• Quick Intubation• Extubation after full recovery

Treatment

• Pharyngeal Suction• Intubation• Broncheal lavage• Positive Pressure

Ventilation • Bronchodilators