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Mar: Sem 4 - Principles II > Exam 3: PONV > Flashcards

Exam 3: PONV Flashcards

1
Q

When does nausea peak in patients post-operatively?
How long does nausea/vomiting typically last post operatively?

A

Peak: 6 hours
Persists for 24 - 48 hours

S3

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2
Q

What is the most common pt complaint?

A

Nausea or vomiting

overall incidence 20-30% with intractable vomiting being 0.1%

S3

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3
Q

What are the four major inherent (patient-specific) risk factors for PONV?

A
  • Female
  • Non-smoker
  • PONV history
  • History of motion sickness

Opioid use not an inherent risk factor.

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4
Q

What are two additional risk factors for PONV that are based on the pt?

A
  • delayed gastric emptying (in states such as DM, GLP-1, gastroporesis etc)
  • Peroperative anxiety

S4

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5
Q

What factor is the greatest cause of PONV from anesthesia?

A

Intraoperative and postoperative opioids.

S5

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6
Q

What is the full list of anesthetic-technique risk factors for PONV?

A
  • Volatile’s
  • Nitrous > 50%
  • Opioids
  • Neostigmine
  • Gastric distention
  • Anesthesia duration
  • Forced PO fluids prior to discharge

Very Nice Opairs Need Gassy Ant’s Feurosemide

S5

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7
Q

What surgeries place a patient at higher risk for development of PONV in adults?

A
  • Longer duration of surgery (relates to long Anesthesia)
  • High risk surgeries
  • ENT surgeries
  • Neuro surgeries
  • Belly surgeries
  • Breast, plastic, strabismus surgery (girly sx’s)
  • Laparoscopy (bc of insufflation)
  • Laparotomy

BEGAN (Belly including laps, ENT, Girly, Anesthesia long, Neuro)

S6

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8
Q

Pediatric PONV incidence increases with age until ____.

A

puberty

S7

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9
Q

Which pediatric procedures are noted to have a higher incidence of PONV?

A
  • Adenotonsillectomy
  • Strabismus repair
  • Hernia repair
  • Orchiopexy
  • Penile surgeries

Also Males and Females experience PONV equally while peds have 2x risk of PONV as adults

OPAHS

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10
Q

Will increased O₂ concentrations increase or decrease PONV occurrence?

A

decrease

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11
Q

Will adequate hydration increase or decrease PONV occurrence?

A

decrease (dehydration induces nausea)

S8

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12
Q

Will nitrous use increase or decrease PONV occurrence?

A

increase

(N2O greater than 50% creates PONV)

S8

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13
Q

Will neuromuscular blockade reversal with acetylcholinesterase inhibitors increase or decrease PONV occurrence?

A

Increase

↑ neostigmine = ↑ PONV

S8

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14
Q

Will minimized motion/ambulation increase or decrease PONV occurrence?

A

decrease (CN VIII)

Let patient guide movement based on how they feel.

S8

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15
Q

Will Propofol increase or decrease PONV?

A

Decrease

Might consider running a very light sedation drip on top of the volatile for super long cases so you don’t run all out of prop

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16
Q

Where is the emetic center of the brain located?

A

Lateral reticular formation of the brainstem

S10

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17
Q

Which substances act directly on receptors of the lateral reticular formation of the brainstem?

A

Trick Question. No substances act directly on the emetic center.

S10

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18
Q

Where does afferent input arrive from to the emetic center?

A
  • Pharynx
  • GI tract
  • Mediastinum
  • Afferent nerves

Perfect Giraffes Manhandle Astronauts

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19
Q

Where does CNS afferent input to the emetic zone come from?

A
  • Chemotactic Zone (CTZ) of the area postrema
  • Vestibular portion of Vestibulocochlear nerve (CN VIII)

S10

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20
Q

The CTZ of the area postrema does not have the ____.
What are the implications of this?

A

Blood brain barrier (BBB)

No BBB means chemicals and drugs in the blood or CSF can trigger N/V.

S11

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21
Q

What receptors are located in the Chemoreceptor Trigger Zone?

A
  • Dopamine
  • Serotonin 5-HT3
  • Opioid
  • Histamine
  • Muscarinic
  • Neurokinin-1
  • Cannabinoid

Dale (Dr. T!) Consumed 5 Olives. His Magnificent Nutrition…

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22
Q

What drug is the gold standard for PONV prophylaxis and treatment?

A

Trick question. No single drug is gold standard.

S13

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23
Q

Patients (should / should not) receive the same drug for prophylaxis and treatment of PONV.

A

Should not.

Ex. If ondansetron is used for prophylaxis, use promethazine for treatment

s13

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24
Q

When it comes to anti-emetics more is ____ (better, or worse.)

A

Better

S14

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25
Q

Opioid premedication in Preop will ____ risk of PONV.
Benzodiazepine premedication in Preop may ____ risk of PONV.

A

Increase

Decrease

S15

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26
Q

What induction drug(s) increase risk of PONV?

A
  • Volatiles’s
  • Etomidate
  • Ketamine

S15

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27
Q

What induction drug(s) decrease risk of PONV?

A

Propofol

S15

28
Q

What volatile agent is associated with PONV (especially in concentrations greater than 50%)?

A

Nitrous Oxide

S15

29
Q

One single dose of an opioid is not enough to cause PONV. T/F?

A

False. A single dose can cause PONV.

S16

30
Q

Greater than ____mg of Neostigmine is associated with increased PONV risk.

A

> 2.5mg

Dose dependent: ↑ neostigmine = ↑ PONV.

S16

31
Q

What drug could reduce the PONV associated with neostigmine?

A

Atropine

can use glyco for HR, but glyco doesn’t decrease PONV
Atropine dose is 7-10 mcg/kg just in case Corn gets crazy with “you learned it 1000 years ago, you need to know it”

S16

32
Q

What is the mechanism of action of PONV induced by neostigmine?

A

Thought to be muscarinic actions on the GI tract

Lecture

33
Q

At how many risk factors is PONV prophylaxis indicated?

A

S17

34
Q

PONV algorithm

Low risk and low risk of medical sequela

A

No prophylaxis but reduce baseline risk - rescue using 5HT3

S18

35
Q

PONV Algorithm

Low risk and high risk of medical sequela

A
  • Prophylaxis: 5HT3
  • rescue with different classes: Phenothiazine, antihistamine or metoclopramide

S18

36
Q

PONV Algorithm

Moderate risk with any risk of medical sequela

A
  • Prophylaxis: 5HT3 + steriod
  • Rescue with different classes: Phenothiazine, antihistamine, or metoclopramide

S18

37
Q

PONV Algorithm

High risk with any risk of medical sequela

A
  • Prophylaxis: 5HT3 + steroid + propofol TIVA + scop patch
  • Rescue using different classes: Phenothiazine, antihistamine or metaclopramide

S18

38
Q

What is P-6 stimulation?

A

Radial compression from acupuncture and acupressure

S20

39
Q

How is P-6 manipulation thought to treat PONV?

A

P-6 compression → Hypophyseal secretion of β-endorphins → inhibition of CTZ.
Also decreases acid secreation

S20

40
Q

Is P-6 manipulation good at treating nausea and vomiting?

A

No really, better at inhibition.

might be effective early in Preop

S20

41
Q

What are the subtypes of anti-dopaminergics that are used to treat PONV?

A
  • Butyrophenones
  • Phenothiazines

S21

42
Q

What are the side effects of dopamine receptor antagonists?

A
  • Drowsiness/sedation
  • Extrapyramidal s/s

These are also antipsychotic and neuroleptic agents too

S21

43
Q

What drugs are butyrophenones?

A

Haloperidol
Droperidol

S22

44
Q

What black box warning exists for Droperidol?

A

Torsades de Pointes and sudden death.

S22

45
Q

More than ____ mg of droperidol should never be given.

A

0.625mg

Dr. M says the people that DO give it start with a 0.3mg dose

S22

Give SLOW

46
Q

Droperidol is as effective as ___________ for treatment of PONV.

A

Ondansetron 4mg

S22

47
Q

Droperidol also has effects as a ____ thus resulting in hypotension.

A

weak α blocker

S22

48
Q

What drugs are phenothiazines?

A

Prochlorperazine
Chlorpromazine
Promethazine

S23

PPCP (Like PCP, but you studder at first)

49
Q

What black box warnings are there for promethazine?

A
  • Tissue damage
  • Resp arrest for < 2yo’s

Must be diluted and pushed very slowly

S23

50
Q

What receptors does promethazine act on?

A
  • Anti-dopamine
  • Anti-histamine
  • α adrenergic
  • muscarinic/cholinergic

MAAA!

S23

51
Q

What are known side effects of promethazine?

A
  • Sedation
  • Hypotension
  • EPS

S23

52
Q

Dose of Promethazine

A

12.5-25 mg

S23

Just like benadryl dosing
- we learned in anesthesia pharm that benadryl dose was 25-50mg tho
- you right

53
Q

How do 5HT3 Antagonists work in the treatment of nausea/vomiting?

A

Antagonize serotonin receptors on the vagal nerve and CTZ

S24

54
Q

Chronic use of 5HT3 antagonists can result in mild elevation of what?

A

Liver enzymes

S24

55
Q

When should ondansetron be given?

A

4mg within 15 - 20 min of surgery end.

Data unclear of 4mg vs 8mg

S24

56
Q

What anticholinergic is given for PONV prophylaxis?
What dose and route is utilized?

A

Scopolamine 1.5mg transdermal patch and left in place for 48-72 hours

S25

57
Q

What is the PONV rescue dose of dexamethasone?

A

Trick question. Dexamethasone should be used for prophylaxis only.

S26

58
Q

When is dexamethasone given and what dosage is utilized?

A

Given during or immediately after induction. 4mg (just as effective as 8mg)

S26

59
Q

How does metoclopramide combat PONV? dose?

A

Increases LES tone and GI motility.

Not very efficacious. 10 - 20mg IV

S27

60
Q

What NK-1 antagonist is given for PONV? How does it work?

A

Aprepitant (Emend):

  • antagonizes substance P in the emetic center.
  • Depresses Neucleus tractus soltarius (NTS) activity (this is the area where the NK-1 receptors are which are activated by Sub P)
  • Blocks afferent messages from enterochromaffin cells

Nurses Embalmed Peas

S28

61
Q

What is the aprepitant dose?

A

40mg or 125mg
- given 2-3 hours prior to induction which is difficult to time, so give it as early as possible in preop

This has better effects on vomiting over nausea

S28

62
Q

How does propofol prevent/treat PONV?

A

Blocks serotonin release in subhypnotic doses.

May also inhibit CTR.

S29

63
Q

What is the subhypnotic dose of propofol?

A

16.7 mcg/kg/min

S29

64
Q

What drug needs to be given alongside propofol?

A

Glycopyrrolate (to counteract bradycardia)
Glyco dose: 7-15 mcg/kg (1mg max)

S29

65
Q

____ has been associated with a 50% reduction in nausea.

A

Isopropyl alcohol

S30

66
Q

What is the dose for prehydration to decrease nausea?

A

10-30 mL/kg

67
Q

What other non-pharmachologic choices could decrease PONV?

A
  • accupuncutre/accupressure
  • Adequate pre-hydration (10-30 ml/kg)
  • Carbohydrate loading (theory - but stabalize BG can potentially help)
  • Aromatherapy
    • Peppermint: not effective
    • Isopropyl alcohol: 50% reduction in nausea
  • Ginger (No significant reduction)
  • Chewing gum (Potential improvement in nausea; stimulates GI motility)

S30

Mar: Sem 4 - Principles II (27 decks)

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