Exam 3 (PONV)

Question 1

• When does PONV peak & how long can it last?

Answer 1

• Peaks at 6hrs &
• Lasts 24-48hrs

Question 2

• What are the general risk factors for PONV?

Answer 2

• Female,
• non-smoker
• History of PONV
• History of motion sickness.
• Some anxiety &
• delayed gastric emptying

Question 3

• What are PONV risk factors for adults?

Answer 3

• Intraop opioids.
• Volatiles
• Longer anesthesia
• Neostigmine
• Nitrous oxide
• Gastric distention
• Mandatory PO fluids before D/C

Question 4

• What are some high-risk surgeries causing PONV?

Answer 4

• Laparoscopy
• ENT surgeries
• Neurosurgery
• Laparotomy
• Breast sx
• strabismus sx
• plastic Sx

Question 5

• What are specific pediatric surgeries that increase PONV instances?

Answer 5

• Adenotonsillectomy,
• Strabismus,
• Hernia repair,
• Orchiopexy,
• Penile Sx

Question 6

• What are strategies to reduce PONV?

Answer 6

• Regional anesthesia,
• Propofol,
• hydration,
• avoid NO2,
• TIVA,
• Minimize Neostigmine,
• minimize motion & early ambulation

Question 7

• Where is the emetic center located & what drugs act on it?

Answer 7

• In the lateral reticular formation.
• No drugs act on it directly

Question 8

What locations send stimuli to the emetic center?

Answer 8

• Pharynx,
• GI tract
• Mediastinum,
• Higher brain centers,
• Vestibular portion of CN8

Question 9

• What are the PONV trigger zone receptors?

Answer 9

• Dopamine,
• serotonin,
• 5-HT3,
• Opioid,
• histamine,
• muscarinic,
• Neurokinin-1,
• cannabinoid

Question 10

• Do benzos increase or decrease PONV?

Answer 10

Decrease

Question 11

• What induction drugs increase the risk for PONV?

Answer 11

• Volatiles,
• ketamine,
• etomidate,
• NO2

Question 12

• What reversal drug increases PONV & what decreases?

Answer 12

• Increase: Robinul, neostigmine
• Decrease: atropine

Question 13

• At what Apfel score do we treat prophylactically?

Answer 13

At 2 risk factors (39%)

Question 14

• What is the PONV algorithm for low risk?

Answer 14

• Prophylaxis with 5-HT3 antagonist &
• rescue w/ different class

Question 15

• What is the PONV algorithm for moderate risk?

Answer 15

• Prophylaxis w/ 5-HT3 & steroid (dexamethasone)
• rescue w/ different class

Question 16

• What is the PONV algorithm for high risk?

Answer 16

• Prophylaxis w/ 5-HT3, steroid & propofol/TIVA
• rescue w/ different class

Question 17

• Activating the P6 spot results in?

Answer 17

• Secretion of beta-endorphins.
• Decreased acid secretion

Question 18

• Which drugs are butyrophenones?

Answer 18

• Haldol &
• Droperidol (Enapsine)

Question 19

• What is the Droperidol dose for PONV?

Answer 19

Less or equal to 0.625mg

Question 20

• What are the side effects of Droperidol?

Answer 20

• Hypotension &
• Black box for Torsades

Question 21

• What receptors does promethazine assert its effects?

Answer 21

• Alpha adrenergic,
• histamine,
• muscarinic cholinergic receptors

Question 22

• What is the black box warning for promethazine?

Answer 22

• Tissue damage &
• respiratory arrest in children < 2yrs

Question 23

• What are the side effects of Zofran?

Answer 23

• HA
• constipation &
• mild elevated liver enzymes

Question 24

• Where does Zofran assert its effects?

Answer 24

• On the vagal nerve &
• CTZ (chemoreceptor trigger zone)

Question 25

• What is the Scopolamine patch dose?

Answer 25

1.5mg

Question 26

• What are the placement areas for scopolamine patches?

Answer 26

• Thin area of skin & not in sun-exposed areas.
• Upper chest/arm,
• lower abd/hip

Question 27

• What are the side effects of scopolamine?

Answer 27

• Drowsiness
• dry mouth
• dizziness

Question 28

• When should dexamethasone be given?

Answer 28

During or just after induction

Question 29

• How does Reglan work?

Answer 29

Increases LES & GI motility

Question 30

• What is the Reglan dose?

Answer 30

10 – 20 mg IVP

Question 31

• How does Aprepitant work?

Answer 31

Antagonizes substance P in the emetic center

Question 32

• What is the dose for Aprepitant?

Answer 32

40 – 125 mg

Question 33

• When is Aprepitant most useful?

Answer 33

• For active vomiting
• Not as good as an anti-nausea

Question 34

• When is Aprepitant given?

Answer 34

2 – 3 hrs prior to induction

Question 35

• Where does propofol assert its effects?

Answer 35

Blocks serotonin release @ 5-HT3 receptors

Question 36

• What is the subhypnotic/TIVA dose for propofol?

Answer 36

16.7 mcg/kg/min

Question 37

• What is given in conjunction with propofol?

Answer 37

Glycopyrrolate (Robinul) for bradycardia

Question 38

• What are some other choices to reduce PONV?

Answer 38

• Pre-hydration 10 – 30 ml/kg
• Carb loading
• Aromatherapy
• Ginger
• Chewing gum

Question 39

• What are the PONV risk factors for Peds?

Answer 39

• Male = Females
• Vomiting 2x that of adults
• PONV increases with age