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Nausea and Vomiting and You

Nausea and Vomiting and You. Dana Daidone D.O. Consensus Guidelines Prophylaxis for PONV 2003 IARS. 5-HT3 blockers work better for vomiting than nausea and to be given at END of surgery. Decadron 4mg good for N/V and to be given BEFORE induction.

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Nausea and Vomiting and You

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  1. Nausea and Vomiting and You Dana Daidone D.O.

  2. Consensus Guidelines Prophylaxis for PONV 2003 IARS • 5-HT3 blockers work better for vomiting than nausea and to be given at END of surgery. • Decadron 4mg good for N/V and to be given BEFORE induction. • H-1 blockers (low dose) works as well as 5-HT3 blockers • Transdermal scopolamine takes 2-4 hrs to work and has many contraindications, even though it does work • Only moderate to high risk patients should even be given prophylaxis – no drug is benign – we now know that zofran causes dystonic reactions !

  3. Believe it or not, • If it were not for the whole ‘black box’ fiasco, droperidol would have been the panel’s overwhelming first choice for PONV prophylaxis….

  4. What doesn’t work - • Reglan when used in standard clinical doses (10 mg IV) is ineffective for PONV prophylaxis • Only one study showed that reglan 20 mg was comparable to 8mg zofran for lap chole if given at the END of the case – but of course there’s no indication to use these high doses of either drug anyway…..

  5. If the pt. received no prophylaxis • And they’re sick in the PACU, give a small dose (1mg) of 5-HT. it works as well as the 4mg dose.

  6. If they got decadron • But are still sick in the PACU, give the small dose (1mg) of 5-HT3 blocker

  7. If the pt. got both drugs • And they’re still sick in PACU, move onto another drug class. You have 2 to choose from – • Droperidol .625 mg • OR • Phenergan / benadryl 12.5 mg

  8. If the pt. is still sick despite ‘triple therapy’ • The triple therapy should NOT be repeated within 6 hours of administration • Zofran and droperidol can be given q6 hrs • Decadron can be given q8 hrs • Small doses of propofol (20 mg) have been shown to work to ‘break the cycle’ in the PACU if all else fails

  9. Who’s at risk for PONV • Female • Nonsmoker • History of ‘weak stomach’ • Narcotic use • Incidence with none,1,2,3,or 4 risk factors is 10%, 20%, 40%, 60%, and 80%

  10. Is type of surgery important? • It is not an independent risk factor for PONV • When other risk factors, such as type of anesthetic and duration of surgery were considered, a causal effect on PONV by type of operation could not be established.

  11. If you don’t want your pt. to puke • Use regional for anesthetic and for post-op • Avoid nitrous AND volatile inhaled agents • If they have to go to sleep, use TIVA • Keep pts. hydrated (1 L pre-op at least) • Use NSAID’s – reduce narcotic use by 30% • Avoid neostigmine at end of surgery – 2.5mg and above makes you puke

  12. A multimodal approach to reduce PONV • Pre-op anxiolysis and aggressive hydration • Decadron & droperidol pre-op • Zofran at the end of surgery • Inspired fiO2 > 80% • TIVA with propofol & remifentanil • Toradol • NO nitrous or paralysis

  13. The results with this approach • Pts. with multimodal tx – 98% complete response rate • Pts. given antiemetic monotherapy – 75% response rate • Pts. given routine anesthetic plus saline placebo – 50% response rate

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