Post operative Nausea and Vomiting

Transcription

1 Post operative Nausea and Vomiting Prevention and Treatment Division of Oral and Maxillofacial Surgery Deepak Krishnan DDS Objective To explore and apply current evidence based medicine to our management of PONV To increase patient satisfaction To maximize cost effectiveness To facilitate efficient patient discharge 1

2 Socio economic Aspects of PONV Common complication of surgery Limiting factor in early discharge Leading cause of unanticipated hospital admission Increased recovery room time, increased nursing care and potential hospital admission: All increase Total Health Costs Socio economic Aspects of PONV High Levels of Patient discomfort and dissatisfaction PONV may be of greater concern than post op pain Patients willing to spend up to $ 100 out of pocket for effective antiemetic 2

3 Socio economic Aspects of PONV 25 30% of surgical patients experience nausea and/or vomiting post operatively Intractable PONV about 0.18% High risk patients may have 70 80% incidence of PONV Emphasis shift from in patient to out patient surgery has increased interest in prevention and treatment of PONV Socio economic Aspects of PONV Optimal approach to PONV remains unclear: Treat all high risk patients? Ideal rescue therapy Published evidence suggests universal PONV prophylaxis in not cost effective Guidelines for prevention of PONV have been published 3

4 7 Muscular contractions associated with nausea and vomiting 8 4

5 Schematic representation of factors influencing nausea and vomiting 9 A final pathway for nausea

6 Major causes of nausea and vomiting Drug/treatment - induced Labyrinth disorders Endocrine causes Infectious causes Increased intracranial pressure Post-operative CNS causes Cancer chemotherapy Opiates Nicotine Antibiotics Radiotherapy Motion Meniere's disease Pregnancy Gastroenteritis Viral labyrinthitis Haemorrhage Meningitis Anaesthetics Analgesics Procedural Anticipatory Migraine Bulimia nervosa 11 Risk Factors for PONV in Adults Patient specific Risk Factors Age (adult) Non smoking status History of PONV / motion sickness Predisposing gastric disorders Low threshold for nausea Preoperative anxiety Obesity (disputed in recent studies) Gastric distension (disputed in recent studies) Am J Health Syst Pharm 1999;56:

7 Risk Factors for PONV in Adults Anesthetic Risk Factors Pre anesthetic medications (opioids, atropine) Volatile anesthetics Nitrous Oxide Intraoperative or postoperative use of opioids Duration of anesthesia (> 120 min) Risk Factors for PONV in Adults Surgical Risk Factors Duration of surgery (each 30 min increases PONV risk by 60%) Type of surgery (craniotomy; head and neck procedures; major breast procedures; strabismus surgery; laparoscopy; laparotomy). Intubation (disputed in recent studies) Early oral intake 7

8 Consensus Guidelines for the management of PONV Anesthesia and Analgesia Jan 2014 Updated guidelines since the 2003 and 2007 Current and comprehensive info based on a systematic literature review Strategies to prevent and treat PONV in children and adults Consensus on (1) risk for PONV in adults and postoperative vomiting (POV) in children (2) Establish factors that reduce the baseline risks for PONV (3) Determine the most effective antiemetic single drug and combination therapy regimens for PONV/POV prophylaxis, including pharmacologic and nonpharmacologic approaches (4) Ascertain the optimal approach to treatment of PONV and PDNV with or without PONV prophylaxis (5) Determine the optimal dosing and timing of antiemetic prophylaxis (6) Evaluate the cost effectiveness of various PONV management strategies (7) Create an algorithm to identify individuals at increased risk for PONV and suggest effective treatment strategies (8) Propose a research agenda for future studies 8

9 Guideline 1 Who is at risk? The riskiest Consensus Guidelines for the Management of Postoperative Nausea and Vomiting Gan, Tong J.; Diemunsch, Pierre; Habib, Ashraf S.; Kovac, Anthony; Kranke, Peter; Meyer, Tricia A.; Watcha, Mehernoor; Chung, Frances; Angus, Shane; Apfel, Christian C.; Bergese, Sergio D.; Candiotti, Keith A.; Chan, Matthew TV; Davis, Peter J.; Hooper, Vallire D.; Lagoo Deenadayalan, Sandhya; Myles, Paul; Nezat, Greg; Philip, Beverly K.; Tramèr, Martin R. Anesthesia & Analgesia. 118(1):85 113, January doi: /ANE Table 1. Risk Factors for PONV in Adults Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins. 18 9

10 Risk Scoring for ponv Consensus Guidelines for the Management of Postoperative Nausea and Vomiting Figure 1. Risk score for PONV in adults. Simplified risk score from Apfel et al.9 to predict the patient s risk for PONV. When 0, 1, 2, 3, and 4 of the risk factors are present, the corresponding risk for PONV is about 10%, 20%, 40%, 60%, and 80%, respectively. PONV = postoperative nausea and vomiting. Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins. 19 Simplified risk score for POV in Children Figure 3. Simplified risk score for POV in Children. Simplified risk score from Eberhart et al.48 to predict the risk for POV in children. When 0, 1, 2, 3, or 4 of the depicted independent predictors are present, the corresponding risk for PONV is approximately 10%, 10%, 30%, 50%, or 70%, respectively. POV = postoperative vomiting; PONV = postoperative nausea and vomiting. Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins

11 Strategies to reduce baseline risk The IMPACT study 6 strategies to reduce PONV in 5199 high risk patients (1) The avoidance of general anesthesia by the use of regional anesthesia (2) Preferential use of Propofol infusions (3) Avoidance of nitrous oxide (4) Avoidance of volatile anesthetics (5) Minimization of perioperative opioids (6) Adequate hydration *Apfel et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med. 2004;350: Strategies to reduce baseline risk Table 2. Strategies to Reduce Baseline Risk Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins

12 Minimizing post op Opioids Baseline risk for PONV can also be reduced by minimizing postoperative opioids. alternate modalities of pain management perioperative (NSAIDs), cyclooxygenase 2 inhibitors and intraoperative ketamine may have a morphine sparing effect in the postoperative period. Other updated strategies supplemental oxygen had no effect on nausea or vomiting minimizationof of neostigminedosagedoes does notreduce the baselinerisk Children receiving intraoperative propofol in subhypnotic doses (bolus of 1 mg/kg followed by an infusion at 20 mcg/kg/min) combined with dexamethasone had less emesis than those receiving dexamethasone alone a combination of sub hypnotic propofol and tropisetron provided better prophylaxis against tpov than Tropisetron alone in this patient t population routine gastric decompression and limiting oral intake after surgery were ineffective in reducing emesis in the postoperative period in children 12

13 Discards music therapy isopropyl alcohol linhalation intraoperative gastric decompression the proton pump inhibitor esomeprazole ginger root nicotine patch to nonsmokers cannabinoids (nabilone and tetra hydrocannabinol) intraoperative supplemental oxygen Some evidence a new meta analysis on P6 stimulation The timing of acupoint P6 electrical stimulation did not impact PONV with similar reductions in PONV achieved when the stimulation was initiated either before or after anesthesia induction Neuromuscular stimulation over the median nerve reduced PONV in the early postoperative period, particularly when tetanic stimulation was used 13

14 Some evidence Morindal citrofolin linn (noni fruit) showed effectiveness in reducing early postoperative nausea. A small dose (2 mg) of midazolam when given toward the end of surgery is effective in reducing PONV. adequate IV fluid hydration was effective to reduce PONV the type of fluid (crystalloid versus colloid) did not have an effect on PONV when similar volumes were used in surgeries with minimal fluid shifts Hydration 14

15 Guideline 3 Administer PONV Prophylaxis Using 1 to 2 Interventions in Adults at Moderate Risk for PONV What's new? (1) 5HT 3 receptor antagonists: ramosetron and palonosetron; (2) NK 1 receptor antagonist: aprepitant, casopitant, and rolapitant; (3)corticosteroid: methylprednisolone; (4) butyrophenone: haloperidol; (5) antihistamine: meclizine. Prophylaxis for Ponv While PONV prevention is recommended in a subset of patients, current evidence does not support giving prophylactic antiemetics to all patients who undergo surgical procedures. 15

16 Prophylaxis for Ponv recommended pharmacologic antiemetics for PONV prophylaxis in adults 5 hydroxytryptamine (5 HT 3 ) receptor antagonists (ondansetron, dolasetron, granisetron, tropisetron, ramosetron, and palonosetron) neurokinin 1 (NK 1) receptor antagonists (aprepitant, casopitant, and rolapitant) corticosteroids (dexamethasone and methylprednisolone) Butyrophenones (droperidol and haloperidol) antihistamines (dimenhydrinate and meclizine) anticholinergics (transdermal scopolamine [TDS]) Prophylactic dose and timing of antiemetic Table 3. Antiemetic Doses and Timing for Prevention of PONV in Adults Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins

17 Ondansetron 4 mg, droperidol 1.25 mg, dexamethasone 4 mg equally effective, and each independently reduced PONV risk by approximately 25%. Recommendations given are evidence based and not all the drugs have a Food and Drug Administration (FDA) indication for PONV 5 HT 3 Receptor Antagonists Ondansetron Zofran Most available research gold standard compared with other antiemetics recommended dose of 4 mg IV The effect of the ondansetron 8 mg oral disintegrating tablet = to the 4 mg IV dose Ondansetron is as effective as other 5 HT 3 s as effective as dexamethasone and haloperidol 1 mg IV (with no difference in effect on the QTc interval) Most effective when given at the end of surgery Generally safe 17

18 Nk 1 Receptor Antagonists Aprepitant Emend 40 hour half life Aprepitant p (40 and 80 mg) similar to ondansetron in achieving complete response (no vomiting and no use of rescue antiemetic) for 24 hours after surgery significantly more effective than ondansetron for preventing vomiting at 24 and 48 hours after surgery and in reducing nausea severity in the first 48 hours after surgery greater antiemetic effect compared with Ondansetron Whenused in combination, Aprepitant 40 mg per os, plus dexamethasone, is more effective than Ondansetron plus dexamethasone in preventing POV in patients undergoing craniotomy clinical experience is limited, and its role in routine prophylaxis is not established Corticosteroid Dexamethasone prophylactic dose of 4 to 5 mg IV for patients at increased risk for PONV is recommended after anesthesia induction rather than at the end of surgery dexamethasone 4 mg IV is similar to ondansetron 4 mg IV and droperidol 1.25 mg IV recent studies increasingly use the higher dose of dexamethasone 8 mg IV rather than the minimum effective dose of 4 to 5 mg enhances the post discharge quality of recovery in addition to reducing nausea, pain, and fatigue required less opioid and reported less nausea, sore throat, muscle pain, and difficulty falling asleep Safety inconclusive 18

19 Butyrophenones Droperidol Butyrophenones Droperidol Prophylactic doses of droperidol to 1.25 mg IV are effective for the prevention of PONV efficacy of droperidol is similar to ondansetron for PONV prophylaxis is most effective when administered at the end of surgery 19

20 Droperidol doses used for the management of PONV are extremely low, at these dosing levels, Droperidol is unlikely to be associated with significant cardiovascular events several studies have documented the equal QTc effects of Droperidol versus Ondansetron Scopalamine patch useful as an adjunct to other antiemetic therapies. patch effectively prevented nausea and vomiting postoperatively up to 24 hours can be applied the evening before surgery or 2 to 4 hours before the start of anesthesia (2 to 4 hour onset of effect) adverse events associated with TDS are generally mild, the most commonbeing visualdisturbances disturbances, dry mouthand dizziness new data equal effectiveness with single drug therapy using TDS, Ondansetron, or Droperidol 20

21 Propofol as an antiemitic Propofol used as part of TIVA is recommended to reduce baseline risk for PONV use of Propofol for induction and maintenance of anesthesia decreases the incidence of early PONV (occurring within the first 6 hours) Propofol, in small doses (20 mg as needed), can be used for rescue therapy for patients t in the direct care environment, for example, PACU, and has been found as effective as Ondansetron What else can I throw in the fire? Alpha 2 agonists Clonidine, Precedex Midazolam Gabapentin PCA 21

22 Guideline 4 Administer Prophylactic Therapy With Combination ( 2) Interventions/Multimodal Therapy in Patients at High Risk for PONV The combos midazolam and dexamethasone dexamethasone 8 mg IV at induction plus ondansetron 4 mg IV at the end of surgery plus ondansetron 8 mg PO postoperatively haloperidol 2.5 mg plus dexamethasone 5 mg IV after induction 22

23 Pharmacologic Combination Therapy for Adults and Children Table 4. Pharmacologic Combination Therapy for Adults and Children Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins. 45 Guideline 5 Administer Prophylactic Antiemetic Therapy to Children at Increased Risk for POV; As in Adults, Use of Combination Therapy Is Most Effective 23

24 Algorithm for management of postoperative nausea and vomiting Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins. Antiemetic Doses for Prophylaxis of POV in Children Table 5. Antiemetic Doses for Prophylaxis of POV in Children Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins

25 POV rate can be twice as high as in adults large volume of data prophylaxis with a combination of a 5 HT 3 antagonist +steroid most pediatric patients at high risk for POV use of steroids in children at risk for tumor lysis syndrome the use of 5 HT 3 antagonists in children with prolonged QT syndrome. Guideline 6 Provide Antiemetic Treatment to Patients With PONV who did not Receive Prophylaxis or in whom Prophylaxis Failed 25

26 Algorithm for management of postoperative nausea and vomiting Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins. Catch up When nausea and vomiting occur postoperatively treatment should be administered with an antiemetic from a pharmacologic class that is different from the prophylactic drug initially given or if no prophylaxis was given, the recommended treatment is a low dose 5 HT 3 antagonis repeating the medication given for PONV prophylaxis within the first 6 hours after the initial iti ldose conferred no additional benefit an evaluation should be performed to exclude an inciting medication or mechanical factor for nausea and/or vomiting 26

27 Pharmacologic Combination Therapy for Adults and Children Table 4. Pharmacologic Combination Therapy for Adults and Children Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins. 53 Isopropyl Alcohol isopropyl alcohol inhalation is not effective for the prophylaxis of PONV aromatherapy with isopropyl alcohol was effective in achieving a quicker reduction in nausea severity comparable to promethazine or Ondansetron when used for the treatment of PONV Overall lower levels of evidence; on going research 27

28 Translate to the clinical setting 28

29 Risk Adapted PONV Prevention Algorithm (With No Prevention in Low Risk Patients) Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins. 57 Prevention Algorithm Table 7. PONV Prevention Algorithm in All Patients Including Low Risk Patients Plus Additional Interventions for High Risk Patients Copyright 2014 International Anesthesia Research Society. Published by Lippincott Williams & Wilkins

30 Future of PONV Researching genetic polymorphisms Non pharmacologic interventions Safer, better anesthetic agents and techniques Noni juice cocktail! 30

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