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DH: Principles II > PONV (Exam III) > Flashcards

PONV (Exam III) 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

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2
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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3
Q

What factor is the greatest cause of PONV?

A

Intraoperative and postoperative opioids.

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4
Q

What is the full list of anesthetic-technique risk factors for PONV? 7 (4+3)

A
  • VAA’s
  • Nitrous > 50%
  • Opioids
  • Neostigmine
  • Gastric distention
  • Anesthesia duration
  • Forced PO fluids prior to discharge
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5
Q

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

A
  • ENT surgeries
  • Neuro surgeries
  • Belly surgeries
  • Breast, plastic, strabismus surgery (girly sx’s)
  • Long surgeries
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6
Q

Pediatric PONV incidence increases with age until _______.

A

puberty

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7
Q

Which pediatric procedures are noted to have a higher incidence of PONV? 5

A
  • Adenotonsillectomy
  • Strabismus repair
  • Hernia repair
  • Orchiopexy
  • Penile surgeries
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8
Q

Will increased O₂ concentrations increase or decrease PONV occurrence?

A

decrease

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9
Q

Will adequate hydration increase or decrease PONV occurrence?

A

decrease

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10
Q

Will nitrous use increase or decrease PONV occurrence?

A

increase

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11
Q

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

A

Increase

↑ neostigmine = ↑ PONV

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12
Q

Will minimized motion/ambulation increase or decrease PONV occurrence?

A

decrease

Let patient guide movement based on how they feel.

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13
Q

Where is the emetic center of the brain located?

A

Lateral reticular formation of the brainstem

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14
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.

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15
Q

Where does afferent input originate (prior to arrival at the emetic center)? 5

A
  • Pharynx
  • GI tract
  • Mediastinum
  • Afferent nerves of CTZ and 8th CN
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16
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)
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17
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.

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18
Q

What receptors are located in the Chemoreceptor Trigger Zone?

A
  • Dopamine
  • Serotonin 5-HT3
  • Opioid
  • Histamine
  • Muscarinic
  • Neurokinin-1
  • Cannabinoid
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19
Q

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

A

Trick question. No single drug is gold standard.

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20
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

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21
Q

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

A

Better

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22
Q

Opioid premedication will ______ risk of PONV.
Benzodiazepine premedication may ______ risk of PONV.

A

Increase

Decrease

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23
Q

What induction drug(s) increase risk of PONV?

A
  • VAA’s
  • Etomidate
  • Ketamine
24
Q

What induction drug(s) decrease risk of PONV?

25
What volatile agent is associated with PONV (especially in concentrations greater than 50%)?
Nitrous Oxide
26
One single dose of an opioid is not enough to cause PONV. T/F?
False. A single dose can cause PONV.
27
Greater than ____mg of Neostigmine is associated with increased PONV risk.
> 2.5mg **Dose dependent: ↑ neostigmine = ↑ PONV**.
28
What drug could reduce the PONV associated with neostigmine?
Atropine
29
What is the mechanism of action of PONV induced by neostigmine?
Though to be muscarinic actions on the GI tract
30
At how many risk factors is PONV prophylaxis indicated?
31
What is P-6 stimulation?
Radial compression
32
How is P-6 manipulation thought to treat PONV?
P-6 compression → Hypophyseal secretion of β-endorphins → inhibition of CTZ.
33
Is P-6 manipulation good at treating nausea and vomiting?
No really, better at inhibition.
34
What are the subtypes of anti-dopaminergics that are used to treat PONV?
- Butyrophenones - Phenothiazines
35
What are the side effects of dopamine receptor antagonists?
- Drowsiness/sedation - Extrapyramidal s/s
36
What drugs are butyrophenones?
Haloperidol Droperidol
37
What black box warning exists for Droperidol?
Torsades de Pointes and sudden death.
38
More than ______mg of droperidol should never be given.
0.625mg
39
Droperidol is as effective as ___________ for treatment of PONV.
Ondansetron 4mg
40
Droperidol also has effects as a ______________ thus resulting in hypotension.
weak α blocker
41
What drugs are phenothiazines?
Prochlorperazine Chlorpromazine **Promethazine**
42
What black box warnings are there for promethazine?
- Tissue damage - Resp arrest for < 2yo's
43
What receptors does promethazine act on?
- Anti-dopamine - Anti-histamine - α adrenergic - muscarinic
44
What are known side effects of promethazine?
- Sedation - Hypotension - EPS
45
How do 5HT3 Antagonists work in the treatment of nausea/vomiting?
Antagonize serotonin receptors on the vagal nerve and CTZ
46
Chronic use of 5HT3 antagonists can result in mild elevation of what?
Liver enzymes
47
When should ondansetron be given?
4mg within 15 - 20 min of surgery end.
48
What anticholinergic is given for PONV prophylaxis? What dose and route is utilized? Non-Neostigmine adjunct…
Scopolamine 1.5mg transdermal patch
49
What is the PONV rescue dose of dexamethasone?
Trick question. Dexamethasone should be used for prophylaxis only.
50
When is dexamethasone given and what dosage is utilized?
Given during or immediately after induction. 4mg (just as effective as 8mg)
51
How does metoclopramide combat PONV? Dose/Route
Increases LES tone and GI motility. Not very efficacious. 10 - 20mg IV
52
What NK-1 antagonist is given for PONV? How does it work? 3
Aprepitant: - antagonizes substance P in the emetic center. - Depresses NTS activity - Blocks afferent messages from enterochromaffin cells
53
What is the aprepitant dose?
40mg or 125mg
54
How does propofol prevent/treat PONV? 2
Blocks serotonin release in subhypnotic doses. *May also inhibit CTR*.
55
What is the subhypnotic dose of propofol?
16.7 mcg/kg/min
56
What drug needs to be given alongside propofol?
Glycopyrrolate (to counteract bradycardia)
57
______ ______ has been associated with a 50% reduction in nausea.
Isopropyl alcohol

DH: Principles II (36 decks)

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