PONV (Mordecai) Exam III Flashcards
What is the most common patient complaint postoperatively, as mentioned in the slide?
A) Nausea
B) Vomiting
C) Pain
D) Dizziness
B) Vomiting
Slide 3
What is the overall incidence of postoperative nausea and vomiting?
A) 10-20%
B) 20-30%
C) 30-40%
D) 50-60%
B) 20-30%
Some studies reach as high as 80%
Slide 3
When does postoperative vomiting typically peak?
A) 1 hour postop
B) 3 hours postop
C) 6 hours postop
D) 12 hours postop
C) 6 hours postop
Slide 3
The incidence of intractable vomiting is ________.
A) 0.1%
B) 0.12%
C) 0.15%
D) 1.0%
A) 0.1%
most severe, the severe end of the spectrum
Intractable = hard to control or deal with
Slide 3
Postoperative vomiting can persist for ________.
A) 6-12 hours
B) 12-24 hours
C) 24-48 hours
D) 48-72 hours
C) 24-48 hours
True or False
The cause of PONV is well understood and we have identified multiple receptor sites that are targeted to help mitigate the severity of the PONV.
False
Mordecai - The cause of PONV is not thoroughly understood by us but we have identified multiple receptor sites that are implicated in PONV and we target those receptor sites to help mitigate the severity of the PONV.
Slide 3
Which of the following are patient-specific risk factors for PONV? Select 4
A) Non-smokers
B) Female gender
C) Enhanced gastric emptying
D) History of PONV
E) History of diabetes
F) History of motion sickness
A) Non-smokers
B) Female gender
D) History of PONV
F) History of motion sickness - history of sickness in vehicles, on cruises, on fishing trips, in airplanes..
I’m on a boat..
Slide 4
Select the factors that are associated with an increased risk of PONV:
Select 2
A) Preoperative anxiety
B) Delayed gastric emptying
C) Male gender
D) Smokers
A) Preoperative anxiety
B) Delayed gastric emptying - patients with gastroparesis related to diabetes or autoimmune gastroparesis disorders
Slide 4
Which of the following anesthetic agents is associated with an increased risk of postoperative nausea and vomiting (PONV)?
A) Propofol
B) Volatile anesthetics
C) Ketamine
D) Fentanyl
B) Volatile anesthetics
Slide 5
Gastric distention during surgery, often caused by the use of ________, can contribute to the risk of PONV.
A) Nitrous oxide
B) Volatile anesthetics
C) Propofol
D) Neostigmine
A) Nitrous oxide
M - Studies show that Nitrous oxide in concentrations greater than 50% have a positive coorelation with nausea and vomiting, so avoid in patients with hx of PONV
slide 5
Select the things that are commonly associated with increased risk of PONV:
Select 3
A) Intra/Postop opioids
B) Non-volatiles
C) Postoperative opioids only
D) Local anesthetics
E) Preanesthesic medications
F) Duration of anesthesia
A) Intra/Postop opioids
E) Preanesthesic medications
F) Duration of anesthesia
M - The duration of anesthesia is associated with more nausea, probably because the longer the patient is under anesthesia, the more likely in the higher doses of exposure to volatile anesthetics and opioids and other drugs
Slide 5
Which of the following agents or situations can increase the risk of PONV in the postoperative period? Select 3
A) Neostigmine
B) Gastric distention
C) Propofol
D) Mandatory oral fluids before discharge
E) Postanesthetic medication
F) Sugammadex
A) Neostigmine
B) Gastric distention
D) Mandatory oral fluids before discharge
M - we know neostigmine increases free acetylcholine, and that is associated with nausea. We want to avoid excessive uses of neuromuscular blockers that will require high doses of neostigmine to reverse at the end of the case.
More recently we’re leaning heavier on sugammadex in situations where the patient has a history of PONV
Slide 5
Which type of surgery is considered high-risk for PONV?
A) Cataract surgery
B) Laparoscopy
C) Dermatologic surgery
D) Urologic surgery
B) Laparoscopy
M - laparoscopic surgery…this is where we’re insufflating the stomach and causing that CO2 gas is going to put pressure on the GI system and can cause some discomfort and nausea from that.
Slide 6
Which types of surgeries are linked to a higher incidence of PONV due to being close to the chemoreceptor trigger zone (CTZ) and emetic center? Select 2
A) Ear, nose, throat surgery
B) Breast surgery
C) Plastic surgery
D) Cataract surgery
E) Neurosurgery
A) Ear, nose, throat surgery (ENT)
E) Neurosurgery
slide 6
Which of the following surgical factors are associated with an increased risk of PONV?
Select 3
A) Amputation
B) Laparotomy
C) Breast or plastic surgery
D) TIVA
D) Shorter duration of surgery
F) Strabismus
B) Laparotomy
C) Breast or plastic surgery
F) Strabismus
M - ...plastic surgery may be due to the fact that the patient population being younger females, not really clear…and so a lot of times we will do a propofol TIVA on these patients.
Slide 6
Which of the following is true regarding the risk of postoperative nausea and vomiting (PONV) in pediatric patients?
A) The risk increases with age until puberty
B) The risk decreases with age until puberty
C) Males are at higher risk than females
D) The risk is twice that of adults
A) The risk increases with age until puberty
Slide 7
The risk of PONV in pediatric patients is ________ that of adults.
A) Equal to
B) Twice
C) Half
D) Three times
B) Twice
slide 7
Which of the following are true regarding PONV risk factors in pediatric patients?
A) Risk increases with age until mid-life crisis
B) Male and female patients have equal risk
C) Vomiting is twice as common as in peds
D) Risk decreases after puberty
B) Male and female patients have equal risk
Slide 7
Which of the following pediatric procedures are associated with an increased risk of PONV? Select 3
A) Orchiopexy
B) Arthroscopy
C) Strabismus repair
D) Hernia repair
E) Appendectomy
A) Orchiopexy
C) Strabismus repair
D) Hernia repair
Slide 7
Which of the following pediatric procedures are associated with a higher risk of PONV?
Select 2
A) Adenotonsillectomy
B) Orthopedic repair
C) Dental repair
D) Penile surgery
E) Rhinoplasty
A) Adenotonsillectomy
D) Penile surgery
Slide 7
Which of the following are effective strategies for reducing the incidence of PONV?
Select 2
A) Avoiding volatile anesthetics
B) Using steriods
C) Giving nitrous
D) Using propofol TIVA
E) Delaying ambulation after surgery
A) Avoiding volatile anesthetics
D) Using propofol TIVA
M - …we try reducing our volatile anesthetics, so we’ll try to rely more heavily on regional anesthesia and propofol induction TIVA. for anybody that is known to have high risk factors or have a history of PONV.
Helpful Mordecai Hints
Lets say you’re doing a long case, 5-6hr hour mommy makeover for a plastic surgeon. One option is to use your volatile anesthetics and then at the last hour of the case, switch over to a TIVA. Some studies show that’s actually almost as effective as doing a TIVA for the duration of the anesthetic.
Slide 8
What are effective strategies to minimize PONV during surgery?
Select 3
A) Regional anesthesia
B) Maximizing opioid use
C) Intraoperative supplemental O2
D) High doses of neostigmine
E. Adequate hydration
A) Regional anesthesia
C) Intraoperative supplemental O2
E. Adequate hydration
Slide 8
Which strategies are recommended to reduce the risk of PONV?
Select 2
A) Turning volatile on at end of case
B) Local Anesthetic infiltration
C) Non-steroidals
D) Limiting oxygen supplementation
B) Local Anesthetic infiltration
C) Non-steroidals
M - *We want to minimize our opioids, and so we lean on multimodal type medications, like Tylenol and Precedex, and infiltrating the surgical wound with local anesthetics, so that would be the surgeon helping us out there, and non -steroidal medications as well. *
Slide 8
What are effective strategies to minimize PONV during surgery?
Select 2
A) Minimize motion, early ambulation
B) Minimizing suggamadex
C) IM injections of Local Anesthetic
D) Minimize neostigmine
A) Minimize motion, early ambulation
D) Minimize neostigmine
M - it’s important to get them moving, but it needs to be kind of a slow and steady process, just like with the fluid intake. If they get up and moving too quickly, then that can be nausea inducing as well. So no forced ambulation.
Slide 8
Which of the following are consequences of PONV in surgical patients?
Select 3
A) Tension on suture lines
B) Wound strengthening
C) Aspiration
D) Decreased intraocular pressure
E) Dehydration and electrolyte imbalance
A) Tension on suture lines
C) Aspiration
E) Dehydration and electrolyte imbalance
Slide 9
Which factors related to PONV can increase hospital costs?
Select 3
A) Prolonged PACU stay
B) Wound dehiscence
C) Anticipated admissions
D) Reduced surgical time
E) Increased need for personnel
F) Relaxed suture lines
A) Prolonged PACU stay
B) Wound dehiscence
E) Increased need for personnel and resources
M - then if wound dehiscence occurs, then you have to worry about infection, use of antibiotics, unnecessary use of antibiotics, and then the potential for antibiotic resistance.
…whenever the patients are in PACU longer than anticipated, this can cause a backup and delay in new fresh post -op patients coming to recovery because there may not be room for them. This delays their time, and it actually adds to their operating room time, which will add to their cost of surgery.
Slide 9
What are some reasons we care about preventing PONV?
Select 3
A) Increased intracranial pressure
B) Short PACU stay
C) Unanticipated admissions
D) Overhydration and electrolyte balance
E) Increased intraocular pressure
A) Increased intracranial pressure
C) Unanticipated admissions
E) Increased intraocular pressure
Slide 9
Where is the emetic center located?
A) Cerebral cortex
B) Cerebellum
C) Lateral reticular formation
D) Hypothalamus
C) Lateral reticular formation of the brainstem
Slide 10
True of False
Medications act directly on the emetic center to cause nausea
False
No substances act directly on the emetic center
Slide 10
Which structures are involved in sending afferent input to the emetic center?
Select 3
A) Mediastinum
B) Larynx
C) GI tract
D) Vestibular portion of the 9th CN
E) Pharynx
A) Mediastinum
C) GI tract
E) Pharynx
Slide 10
A primary source of afferent input to the emetic center from higher brain centers is in the chemoreceptor trigger zone from ________.
A) Area postrema
B) Cerebral cortex
C) Olfactory nerve
D) Pons
A) Area postrema
Slide 10
Afferent input from the higher brain centers comes from the vestibular portion of the ________ cranial nerve.
A) 5th
B) 8th
C) 10th
D) 7th
B) 8th
Vestibulocochlear Nerve
Slide 10
Why is the chemoreceptor trigger zone (CTZ) particularly sensitive to chemicals and drugs?
A) It has a dense blood-brain barrier
B) It lacks a blood-brain barrier
C) It is located in the spinal cord
D) It only responds to physical stimuli
B) It lacks a blood-brain barrier
M - receptors in this area are sensitive to a variety of neurotransmitters, a variety of chemicals and drugs in the blood or CSF can trigger this area.
Slide 11
Which of the following receptor types are NOT involved in triggering the CTZ’s response to nausea and vomiting?
A) Dopamine
B) 5-HT3
C) Muscarinic
D) Opioid
E) Alpha-adrenergic
F) Cannabinoid
E) Alpha-adrenergic
Refresher: 5-HT3’s are a subtype of serotonin receptor (5-HT) that are found in the central nervous system and in the gastrointestinal tract
Slide 11
Which of the following receptor types are involved in triggering the CTZ’s response to nausea and vomiting?
Select 3
A) Histamine
B) GABA
C) Neurokinin-1
D) Serotonin
E) Leukotrienes
A) Histamine
C) Neurokinin-1
D) Serotonin (5-HT)
Slide 11
Which of the following are NOT true about the studies on PONV management?
Select 3
A) They have a large effect size
B) They are poorly powered
C) They lack standardization
D) They provide a definitive gold standard drug
E) They show consistent outcomes across trials
A) They have a large effect size
D) They provide a definitive gold standard drug
E) They show consistent outcomes across trials
Numerous studies showed:
* Poor effect size
* Poorly powered
* Lack standardization
Slide 13
No single drug is considered a ________ for PONV management.
A) Failure
B) Gold standard
C) Non-effective option
D) First-line choice
B) Gold standard
Slide 13
Which statements about PONV management are accurate?
Select 2
A) Patients should not receive the same drug for prophylaxis and treatment
B) There are multiple gold standard drugs to choose from for PONV
C) Patients should receive the same drug for both prophylaxis and treatment
D) Work should focus on identifying and preventing PONV rather than treating it
E) Standardization is present in most studies
A) Patients should not receive the same drug for prophylaxis and treatment
D) Work should focus on identifying and preventing PONV rather than treating it
Slide 13
When patients received one antiemetic, the incidence of PONV dropped to approximately:
A) 38%
B) 50%
C) 28%
D) 20%
A) 38%
Slide 14
The use of two antiemetics resulted in an incidence of approximately ________.
A) 50%
B) 38%
C) 28%
D) 20%
C) 28%
Slide 14
What was the incidence of PONV when ALL three antiemetics (Ondansetron, Dexamethasone, Droperidol) were used at the same time?
A) 38%
B) 50%
C) 28%
D) 20%
D) 20%
M - if the patient received all three drugs, so Zofran, dexamethasone, droparadol, they saw that it dropped to around 20%.
So significant improvement when you’re tacking on different drugs that target different receptors.
Slide 14
Matching Question
0 risk factors → C. 10%
1 risk factor → D. 20%
2 risk factors → E. 39%
3 risk factors → A. 60%
4 risk factors → B. 79%
Slide 17
Matching
Low risk of PONV, Low risk of medical sequela → (B) Reduce baseline risk with NO prophylaxis with 5HT3 antagonist for rescue
*Low risk of PONV, High risk of medical sequela *→ (C) Reduce baseline risk with 5HT3 antagonist for prophylaxis, rescue using different class
Moderate risk of PONV, Any risk of medical sequela → (D) Reduce baseline risk with 5HT3 antagonist + steroid for prophylaxis, rescue using different class
High risk of PONV, Any risk of medical sequela → (A) Reduce baseline risk with 5HT3 antagonist + steroid + propofol TIVA + scopolamine for prophylaxis, rescue using different class
Slide 18
What is P6 stimulation, and how is it used in the management of postoperative nausea and vomiting (PONV)?
A) P6 stimulation involves applying pressure or acupuncture to a specific point on the inner wrist.
B) P6 stimulation is a pharmacological intervention for PONV.
C) P6 stimulation targets a point on the outer wrist.
D) P6 stimulation is located approximately 5 finger widths above the elbow.
E) P6 stimulation requires the use of antiemetic medications for its effect.
A) P6 stimulation involves applying pressure or acupuncture to a specific point on the inner wrist.
Radial compression
Slide 20
Which of the following is typical application site for a Scopolamine transdermal patch?
A) Behind the ear
B) On the upper chest
C) On the upper outer arm
D) On the lower abdomen
E) On the hip
A) Behind the ear
But can be placed on:
- upper chest
- upper outer arm
- lower abdomen
- the hip
- inner malleous of the ankle
Mordecai: you want to place it in an area where the skin is very thin and vascular so that it can absorb
Slide 25
