ponv corso itinerante 08

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PONV(postoperative nausea and vomiting) from a lecture presented in 2008.At the end there are some more references,not graphs.

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  • 1.the meta-analysis (GuptaA,Wu,CL,Elkassabani,N,Krug,CE,Parker,SD,Fleisher LA.Does the routine prophylactic use of antiemetics affect the incidence of postischarge nausea and vomuint following ambulatory surgery?.Anesthesiology 2003;99:488-95.)Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

2. PONVServizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 3. Hill RP, Lubarsky DA, Phillips-Bute B, Fortney JT, Creed MR, Glass PSA, Gan TJ: Cost-effectiveness of prophylactic antiemetic therapy with ondansetron, droperidol, or placebo. ANESTHESIOLOGY 2000; 92:958-67.prophylaxis with 1.25 mg intravenous droperidol was the most cost-effective approach Cost considerations: acquisition cost of a drug costs of wasted drug the need for adjunctive drugs to manage side effects costs of nursing labor Nursing labor costs are linearly related to the time an individual nurse spends with a patient. However, institutional costs may not increase if a patient spends an additional 15 30 min in the postanesthesia care unit (PACU), unless overtime costs are incurred. improved patient satisfactionThe cost-effectiveness of prophylactic antiemetic therapy depends on: the underlying incidence of PONV and on the costs and effectiveness of the drugs used for prophylaxis. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 4. What drug should be used for PONV prophylaxis in high-risk patients? A more expensive drug may be preferred and reduce total institutional costs if it is more effective or associated with a decreased side-effect profile, a greater patient satisfaction, or an quicker return to work. There is convincing evidence from a systematic review of 54 blinded studies of 7,234 patients that ondansetron is more effective than metoclopramide, but not more effective than 1.25 mg droperidol for PONV prophylaxis in adults. Droperidol has also been shown to be as effective as tropisetron and dolasetron. Antiserotonin drugs are associated with increased headache, whereas central nervous system side effects of dysphoria, restlessness, and drowsiness have been reported with droperidol. However, when the dose of droperidol was limited to 1.25 mg intravenous, the incidence of these central nervous system events did not differ compared with ondansetron. It is also important to note that there were no patient preferences for a specific regimen in the study by Hill et al. In this era of cost containment, the less expensive drug, droperidol, should be used for PONV prophylaxis in the adult patient population until more effective drugs with decreased side effects are developed or the costs of alternative drugs are lowered. Similarly, in the absence of evidence to suggest that any available antiserotonin agent is superior to another in effectiveness or side-effect profile, the least expensive one should be used. In contrast to adults, PONV prophylaxis with droperidol is less effective than ondansetron in children and is associated with increased drowsiness, delayed discharge, and extrapyramidal side effects. The preferential use of ondansetron in this patient population may be justified.Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 5. Postoperative Nausea and Vomiting: Prevention and Treatment Claudio Melloni Anestesia e Rianimazione Ospedale degli Infermi di Faenza(RA)Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 6. AUTHOR(S): Watcha, Mehernoor F., M.D. Anesthesiology 92:931-3, 2000Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 7. Topics Importance of the issue Risk factors Pharmacologic approaches to management Adjuvants (nonpharmacologic) Efficacy versus outcome Prevention versus treatment Postdischarge nausea and vomiting Multimodal management Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 8. Methodological questions(from Visserer et al) definitions of PONV: nausea only, nausea and vomiting vomiting only.This has hampered interstudy comparability. Because we scored nausea, retching, and vomiting independently, our data allowed for alternative end-point definitions. The Venn diagrams in show that PONV is primarily determined by the presence of nausea. When vomiting and retching are combined and taken as one end point, the incidence of PONV is lower, but similar differences between isoflurane and TIVA remain. Accordingly, the results of the various possible PONV end points are comparable, provided that nausea is included. Diversity in methods of data collection may also account for some of the observed differences. Emetic symptoms can be quantified as: retrospective self-report Ospedale di Faenza(RA) Servizio di Anestesia e Rianimazione 9. Importance of the issue PONV is : A limiting factor in the early discharge of ambulatory surgical patients The leading cause of unanticipated hospital admissionPONV may: Increase recovery room time Expand nursing care Increase total health care costs Cause high level of patient discomfort---pain,hematoma,wound dehiscence Cause high level of patient dissatisfaction KO!!! Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 10. Macario A, Weinger M,Carney S, Kim A.Which clinical anesthesia outcomes are important to avoid? Anesth.Analg.1999;89:652-8.20 18 16 14 12 10 8 6 4 2 0distribute $100 among the 10 outcomes , proportionally more money being allocated to the more undesirable outcomes. The dollar allocations were used to determine the relative value of each outcome. vomitogagging sul tubo dolore nausea ricordo senza dolore debolezza residua brivido mal di gola sonnolenzaDal + indesiderabile Al meno indesiderabilerankvalore relativoServizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 11. Sintomi accusati dai pazienti a casa dopo interventi eseguiti in regime di day surgery(da Wu et al.,Anesthesiology 2002).dolore nausea vomito cefalea sonnolenza gir.di testa faticaServizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 12. Quali problemi preferirebbero evitare i pazienti sottoposti a day surgery?(da Jenkins, K.; Grady, D.; Wong, J.; Correa, R.; Armanious, S.; Chung,F.*Post-operative recovery: day surgery patients' preferences Br. J. Anaesth. 2001; 86:272-274)30Valori relativi !25dolore tossire sul tubo et vomito nausea disorientamento mal di gola brivido sonnolenza sete20 15 10 5 0Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 13. Beauregard L, Pomp A, Choinire M. Severity and impact of pain after day-surgery Can J Anaesth 1998 / 45 / 304-11Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)faticaraucedinemal di golacefaleasonnolenzagir.testaPONVI g. II g VII gdolore100 90 80 70 60 % 50 40 30 20 10 0 14. Sintomi accusati dai pazienti a casa dopo interventi eseguiti in regime di day surgery(da Wu et al.,Anesthesiology 2002).dolore nausea vomito cefalea sonnolenza gir.di testa faticaServizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 15. Quali problemi preferirebbero evitare i pazienti sottoposti a day surgery?(da Jenkins, K.; Grady, D.; Wong, J.; Correa, R.; Armanious, S.; Chung,F.*Post-operative recovery: day surgery patients' preferences Br. J. Anaesth. 2001; 86:272-274)30Valori relativi !25dolore tossire sul tubo et vomito nausea disorientamento mal di gola brivido sonnolenza sete20 15 10 5 0Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 16. Beauregard L, Pomp A, Choinire M. Severity and impact of pain after day-surgery Can J Anaesth 1998 / 45 / 304-11Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)faticaraucedinemal di golacefaleasonnolenzagir.testaPONVI g. II g VII gdolore100 90 80 70 60 % 50 40 30 20 10 0 17. Can PONV be predicted? Risk factor analysisServizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 18. Sinclair et al.Can PONV be predicted? Anesthesiology 1999;91:109-18 17,638 consecutive ambulatory surgical patients;>90% ASA I /II 5,812 men and 11,826 women mean ( SD) age of 46.7 21.2 yr. prospectively studied during a 3-yr period ASU of The Toronto Hospital, Western Division telephone interview 24 h after operation was obtained. Preoperative patient characteristics and intraoperative variables were documented on specifically designed, standardized adverse-outcome check-off forms. i.v.24 mg morphine for pain relief and 2550 mg dimenhydrinate for nausea or vomiting.Overall PONV incidence 4.6%:9.1 % at 24 hrs interview. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 19. Sinclair et al.Can PONV be predicted? Anesthesiology 1999;91:109-18 Patients with PONV underwent significantly longer procedures (67 57 min vs. 51 44 min; P < 0.0001), and the duration of their stay in the PACU (72 32 min vs. 49 25 min; P < 0.0001) and the ASU (157 84 min vs. 95 53 min; P < 0.0001) was also significantly longer (). Among patients undergoing general anesthesia, those who experienced PONV during the immediate postoperative period had received significantly higher doses of alfentanil, fentanyl, and midazolam during operation (). The same was true of those who received monitored anesthesia care. Patients experiencing PONV received significantly higher doses of dimenhydrinate in the PACU and ASU (37 19 mg vs. 23 11 mg; P < 0.0001). Among patients who received general anesthesia, those with PONV within 24 h after surgery received significantly higher doses of morphine in the PACU and ASU than did those without PONV (6.3 3.6 mg vs. 5.3 3.5 mg; P = 0.008). Among patients undergoing general anesthesia, 1,225 (12%) received a nondepolarizing muscle relaxant during operation. Five hundred patients (41%) received a reversal agent (483 received neostigmine, 17 received edrophonium) at the end of the procedure. There was no significant difference in PONV between those who received a reversal agent and those who did not (19.2% vs. 15.7%; P = 0.11). Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 20. Sinclair DR, Chung F,Mezei G.Can PONV be predicted? Anesthesiology 1999;91:109-18 Background: R