Management of Postoperative Nausea and Vomiting in the Ambulatory Surgery Center

Educational Objectives

The goal of this program is to reduce perioperative nausea and vomiting. After hearing and assimilating this program, the clinician will be better able to:

1. Cite recent literature about risk factors for perioperative nausea and vomiting.

2. Minimize the occurrence of postdischarge nausea and vomiting.

Summary

Factors affecting vomiting center: cerebral cortex can affect vomiting; anxiety plays role; chemoreceptor trigger zone can be stimulated by many factors, including nitrous oxide, inhalational anesthetics, and opioids; vestibular center stimulates vomiting center directly; use of opioids and history of motion sickness important considerations; pain stimulates vomiting center; opioids have multiple effects

Postoperative nausea and vomiting (PONV): affects ≤30% of patients overall and ≤80% of high-risk patients; decreases satisfaction of patients and increases costs of health care because of unexpected admissions; increases morbidity because of dehydration, aspiration, dehiscence of wounds, and hematomas

Postdischarge nausea and vomiting (PDNV): most pertinent to patients undergoing ambulatory surgery; estimated 60% of surgeries performed as ambulatory cases; patients lack immediate recourse or rescue; can last between 4 and 5 days after discharge; occurs with higher frequency, severity, and level of distress than postoperative pain

Apfel et al (2012): compared risk for nausea, severe nausea, vomiting, and severe vomiting before and after discharge; found numbers increased after discharge; rate of severe vomiting 5% after discharge; rate of PDNV ≈37% (almost double rate of PONV in postanesthesia care unit [PACU]); factors used to assess risk for PONV modified for PDNV; age <50 yr and nausea in PACU added; smoking status removed; only 4.4% of patients received antiemetic prophylaxis of sufficient duration of action to prevent PDNV; patients who received prophylaxis with ondansetron before discharge had higher rate of PDNV; patients who received dexamethasone had decreased rate of PDNV

Guidelines: Gan et al (2014) published consensus guidelines for management of PONV; provided new information about risk factors, scoring system for PDNV, information about new antiemetics, new information about efficacy and risk (eg, QT prolongation), and new combinations and strategies for multimodal therapy

Approach to management of PONV: categories of risk factors include patient-specific, surgery-specific, and anesthetic-specific factors; goal to minimize modifiable baseline risks (eg, avoidance of emetogenic agents), administer appropriate prophylactic agents based on estimated risks, and administer agents for rescue as needed

Risk factors for PONV (Apfel et al, 1999): patient factors include female sex, nonsmoking, history of PONV or motion sickness, and younger age; anesthetic factors include general (vs regional) anesthetic, volatile anesthetics, and nitrous oxide; postoperative opioids, but not intraoperative opioids, risk factor for PONV; surgical factors include cholecystectomy, laparoscopic surgery, and gynecologic surgery

Risk factors for PDNV: include female sex, history of PONV or motion sickness, age <50 yr, postoperative opioids, and nausea in PACU

Risk factors in children (Eberhart et al, 2004): include surgery >30 min, age ≥3 yr, strabismus surgery, and history of PONV in relatives

Reduction of baseline risk: provide adequate hydration; avoid general anesthesia when possible; use propofol for induction and maintenance of anesthesia; avoid nitrous oxide and inhalational agents; minimize use of opioids (particularly postoperatively); neostigmine removed as risk factor; use of supplemental oxygen does not decrease risk; infusions of propofol helpful for children

Prophylaxis: administer prophylaxis for PONV with 1 or 2 interventions to patients at moderate risk; use ≥2 interventions in multimodal approach for patients at high risk

Options for treatment: if prophylaxis fails, administer additional medication from different class; do not readminister medications ≤6 hr of arrival in PACU; do not readminister dexamethasone or scopolamine

Classes of medications: 5-HT3 receptor antagonists — examples include ondansetron and palonosetron; palonosetron has half-life of 40 hr; Nk1 receptor antagonists — aprepitant available only in oral preparation; expensive; corticosteroids — dexamethasone; methylprednisolone 40 mg at beginning of surgery also effective; butyrophenones — droperidol currently unavailable; haloperidol said to work in low doses (0.5-2 mg intravenously) with minimal side effects, but not approved by Food and Drug Administration for this indication; antihistamines and anticholinergic agents — transdermal scopolamine effective; warn patient about side effects; phenothiazines — promethazine currently unavailable; metoclopramide available; additional medications to consider — include propofol 20 µg/kg/min, clonidine, dexmedetomidine, mirtazapine, gabapentin, and midazolam

Additional considerations: administer antiemetic prophylaxis to children at increased risk for PONV; ensure prevention of PONV implemented in clinical setting; use multimodal prevention to facilitate implementation; predischarge planning essential for ambulatory patients at high risk

Readings

Apfel CC et al: A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999 Sep;91(3):693-700; Apfel CC et al: Who is at risk for postdischarge nausea and vomiting after ambulatory surgery? Anesthesiology 2012 Sep;117(3):475-86; Eberhart LH et al: The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients. Anesth Analg 2004 Dec;99(6):1630-7, table of contents; Gan TJ et al: Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014 Jan;118(1):85-113.

Disclosures

For this program, the following has been disclosed: Dr. Schoenwald is a member of the Speakers’ Bureau for Merck and Co. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Schoenwald was recorded at the Survey of Current Issues in Surgical Anesthesia, held November 27-December 1, 2017, in Naples, FL, and presented by the Cleveland Clinic Anesthesiology Institute. For information about upcoming CME opportunities from the Cleveland Clinic, please visit www.ccfcme.org. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AN601202

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.