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. 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 !

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….

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…..

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.

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

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

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

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%

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.

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

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

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