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Principles > PONV > Flashcards

PONV Flashcards

1
Q

When does PONV peak PONV and persist

A

Peaks 6 hours postop
Persists 24-48 hours

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2
Q

Risk Factors for Adults PONV: Patient Specific (6)

A

*Female
*Non-smokers
*History of PONV
*History of motion sickness
Delayed gastric emptying
Preoperative anxiety

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3
Q

Risk factors for Adults PONV: Anesthesia/PACU (8)

A

Volatiles
Nitrous oxide >50%
*Intra/Postop opioids
Neostigmine
Preanesthetic medication
Gastric distention
Duration of anesthesia
Mandatory po fluids before discharge

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4
Q

Risk Factors for Adults PONV: Surgical Factors

A

Longer duration of surgery

High-risk surgery;

Laparoscopy
Ear, nose, throat surgery
Neurosurgery
Laparotomy
Breast, strabismus, or plastic surgery

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5
Q

Risk factors for peds PONV

A

Increases with age until puberty
Male = female
Vomiting 2x adults
Specific pediatric procedures;
-Adenotonsillectomy
-Strabismus repair
-Hernia repair
-Orchiopexy
-Penile surgery

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6
Q

Strategies to reduce risk of PONV

A

Regional anesthesia

Propofol for induction and maintenance

Intraoperative supplemental O2

Adequate hydration

Avoid nitrous

Avoid volatiles

Minimize opioids

Minimize neostigmine

Minimize mandatory motion and early ambulation

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7
Q

Emetic Center location

A

Located in lateral reticular formation of brainstem

No substances act directly on the emetic center

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8
Q

Incoming stimuli to the emetic center come from where? (4)

A

(afferent input)
Pharynx
GI tract
Mediastinum
Afferent nerves from higher brain centers

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9
Q

Afferent nerves from higher brain centers that cause PONV (2)

A

CTZ (chemotrigger tactic zone) from area postrema

Vestibular portion of 8th CN (auditory nerve-> inbalance)

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10
Q

Chemoreceptor Trigger Zone features and receptors

A

Has no BBB
Chemicals, drugs in blood or CSF can trigger

Receptors;
Dopamine
Serotonin (5-HT3)
Opioid
Histamine
Muscarinic
Neurokinin-1?
Cannabinoid?

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11
Q

Data on management of PONV

A

No single drug is gold standard

Patients should not receive the same drug for prophylaxis and treatment

Work on identifying and preventing as treating is +/- effective

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12
Q

Preoperative Prevention of PONV

A

Opioid premedication ↑ risk
BZD may ↓

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13
Q

Induction prevention of PONV

A

Volatiles, ketamine, etomidate ↑ risk

Propofol ↓…short duration; better if used induction and maintainence

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14
Q

nitrous and PONV

A

Associated with PONV
50% and greater

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15
Q

Opioid avoidance and PONV

A

Single dose of morphine associated with…
Regional nerve blocks, high dose acetaminophen, wound infiltration

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16
Q

Nursing protocols for PONV

A

Forcing position changes
Forcing ambulation/early po fluids

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17
Q

Reversal of NMBD and PONV

A

Anticholinesterases: muscarinic actions on GI

Dose related (> 2.5mg of neostigmine-> PONV)

Atropine reduces PONV (give instead of robinol w/ neostigmine)

Give NMBD that aren’t reversed

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18
Q

Apfel score

A

Predictors: female, hx, postop opioids, nonsmoker
Identified high risk procedures: breast, dental, ENT, lap BTL

0 risk factors: 10%
1 risk factor: 20%
2 risk factors: 39% *** prophylaxis indicated
3 risk factors: 60 %
4 risk factors: 79%

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19
Q

Low risk surgery with Low risk of medical sequela treatment for PONV

A

5Ht3 antagonsit

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20
Q

Low risk of PONV with High risk of medical sequela PONV prevention and treatment

A

Prophylaxis; 5HT3

treatment; phenothiazine
antihistamine
metroclopramide

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21
Q

Moderate risk for PONV and any risk of medical sequela Prevention and treatment of PONV

A

Prophylaxis; 5HT3 & Steroid

Treatment; Phenothiazine, antihistamine, metroclopramide

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22
Q

History of PONV with any risk of medical sequela PONV prevention and treatment

A

Prophylaxis; 5HT3, steroid, Propofol TIVA, Scop

Treatment; Phenothiazine, antihistamine, metroclopramide

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23
Q

Acupuncture and Acupressure MOA

A

P 6 stimulation

Results in hypophyseal secretion of beta-endorphins -> And subsequent inhibition of CTZ

Decreases acid secretion

Better at inhibiting nausea than vomiting

24
Q

Anti-dopaminergics Subtypes

A

Butyrophenones
Phenothiazines

25
Q

Anti-dopaminergics MOA

A

Receptor antagonists are anti-emetic
Also antipsychotic and neuroleptic

26
Q

Anti-dopaminergics Side effects

A

Can cause drowsiness, sedation, EPS effects

27
Q

Butyrophenones drugs

A

Haloperidol
Droperidol

28
Q

Haloperidol PONV characteristics

A

Not really approved for PONV
Not approved for IV use

29
Q

Droperidol (inapsine) PONV characteristics/ dose/ side effects and adjuncts

A

never > 0.625 mg

As effective as Ondansetron 4mg

With metoclopramide 10mg more effective

Weak alpha blocker…hypotension

Black box: torsades de pointes and sudden death

30
Q

Phenothiazines Drugs

A

Prochlorperazine (Compazine)
Chlorpromazine (thorazine)
Promethazine (Phenergan)

31
Q

Torsades characteristics

A

type of polymorphic v tach (coming from different places) -> qrs is different (up and down)

Qt is long and being twisted around the horizontal axis

32
Q

Polymorphic v tach from MI treatment

A

Lidocaine
procaindamide

33
Q

Torsades treatment

A

Isoproterenol (speed up atrial rate and over drive the qrs)

Magnesium

34
Q

Promethazine PONV characteristics/ dose/ side effects

A

Also antagonizes alpha adrenergic, histamine, muscarinic cholinergic receptors

Sedation, hypotension, EPS

12.5-25 mg

Black box: tissue damage; respiratory arrest < 2 y/0

35
Q

5HT3 antagonists MOA

A

Antagonize serotonin
On vagal nerve and CTZ

36
Q

Side effects of 5HT3 antagonists

A

Side effects HA, constipation, mild elevation in liver enzymes

37
Q

Examples of 5HT3

A

Dolasetron (Anzemet)
Granisetron (Kytril)
Ondansetron (Zofran)
Palonosetron

38
Q

Ondansetron (zofran) dose

A

4mg within 15-20 of surgery end; data unclear on 4mg vs. 8mg

39
Q

Scopalamine dose and placement

A

1.5 mg transdermal patch; leave in place 48-72 hours

placement; upper chest, upper outer arm, lower abdomen, hip

40
Q

Scopolamine MOA

A

blocks ach

41
Q

Scopolamine SE

A

Causes drowsiness, dry mouth, dizziness
Care with handling

42
Q

Dexamethasone on PONV and dose

A

Decrease postop pain and edema
Anti-inflammatory reaction
No adverse side effects
Not useful for rescue
Glycemic effect?

Dose: 4mg as effective as 8mg
Given during/just after induction

43
Q

Gastrokinetics drugs

A

Metoclopromide (Reglan)

44
Q

Metoclopromide (Reglan) effect

A

Increases LES tone and GI motility

Less efficacious than droperidol

45
Q

Metoclopromide (Reglan) dose and SE

A

½ of studies indistinguishable from saline
Restlessness, EPS
Dose: 10-20mg IV

Short ½ life…dosing closer to the end of surgery

46
Q

NK-1 antagonists drugs for PONV

A

Aprepitant

47
Q

NK-1 antagonists MOA

A

Antagonize Substance P in the emetic center;
Depress neural activity of the nucleus tractus solitarius

May also interfere with afferent messages from enterochromaffin cells

48
Q

Dose, effects and when to give for Aprepitant

A

Dose 40mg or 125 mg

Greater anti-vomiting than anti-nausea

Given 2-3 hours prior to induction

49
Q

Propofol MOA on PONV

A

Blocks serotonin release at 5HT3 receptors

In subhypnotic doses
May also inhibit CTz

50
Q

Propofol for PONV dose

A

Dose 16.7 mcg/kg/min (subhypnotic) or TIVA dose

51
Q

What to give with prop for PONV for associated bradycardia

A

Glycopyrrolate

52
Q

Prehydration to prevent PONV

A

Adequate pre-hydration
10-30 ml/kg

53
Q

Isopropyl Alcohol on PONV

A

Isopropyl alcohol: 50% reduction in nausea

54
Q

Chewing gum on PONV

A

Potential improvement in nausea; stimulates motility

55
Q

What else could cause PONV (5)

A

Hypotension

Hypoxemia

Elevated ICP

Gastric bleeding

Hypoglycemia

56
Q
A

Principles (34 decks)

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