Instead of frantically signaling for an emesis basin at the first signs of PONV, our nurses can now confidently reassure patients that their nausea, in the rare cases when they do experience it, will pass momentarily. For this, we have our new PONV prevention program to thank.

It starts with screening
Post-operative nausea and vomiting is a significant problem whenever general anesthesia is used. At our plastic surgery facility, that's more than 90% of our cases. Other factors specific to the individual patient and procedure, such as the patient's age, gender and medical history, can increase the risk that the patient will suffer this uncomfortable side effect of anesthesia.

To determine which patients are likely to require pre-operative intervention to prevent PONV, we initiated a PONV risk assessment that became part of each patient's pre-surgery evaluation. We ask patients to complete a checklist when they make their surgical appointments to determine if they have 1 or more of the following PONV risk factors:

• history of PONV;
• history of motion sickness;
• female gender;
• non-smoker;
• history of migraine headaches;
• chronic medical conditions such as indigestion, gastrointestinal problems, peptic ulcer disease or hiatal hernia; and
• scheduled for plastic surgery.

Those with 3 or more risk factors are deemed at a high risk and in need of pre-operative interventions to prevent PONV.

A simple solution
The primary pharmacological intervention we use to prevent PONV in these high-risk patients is Emend (aprepitant), an antiemetic therapy originally designed for chemotherapy-related nausea and vomiting that was approved for PONV prevention in 2006. A 40mg dose of Emend — that's 1 capsule — is designed to stave off PONV over a 48-hour period. Studies have shown that most PONV occurs in PACU or within 48 hours of discharge.

We became aware of the drug's use for PONV prevention in October 2006 and started a quality improvement study to determine if it could help reduce the occurrence of PONV at our facility. A 4-month pilot study involving 20 patients — 10 using Emend and 10 not using Emend — showed that patients who received the drug pre-operatively reported a nausea/vomiting level of 1 to 2 on a 5-point scale, with 5 indicating extreme nausea and vomiting. Patients who were not treated with Emend reported a nausea level of 3 to 4. Patients in the Emend group would report a wave of nausea that would subside; none reported vomiting after surgery. One patient in the non-Emend group did vomit in PACU.

Our patients and physicians were satisfied with the results of the study, so we fully implemented the new system: pre-operative assessments followed by the recommended 40mg dose of Emend. We educate all patients with a risk assessment score of 3 or more about the benefits of Emend, but they ultimately make the decision whether to take it as a preventative measure. The drug costs about $48 to $52 per capsule in our region and the patient is fully responsible for the cost. Patients who decide to take the drug receive a prescription from their primary care physician at their pre-operative appointment. They're instructed to take the capsule with a sip of water 1 hour before surgery. Most patients who've had a history of PONV or motion sickness are more than willing to pay that amount to prevent nausea and vomiting after their procedures, and we've received no reports of side effects or complaints regarding the use of Emend.

Since we implemented the program, less than 13% of our patients with 3 or more PONV risk factors have declined to purchase the drug. For these patients, the alternative pre-operative treatment options are a Dramamine (dimenhydrinate) 50mg tablet 1 hour before surgery or Reglan (metoclopramide) 10mg IVP and a Pepcid (famotidine) 20mg tablet 1 hour before surgery for patients with gastrointestinal problems.

The treatment course depends on the risk assessment determined by our anesthesia provider. We consider the pre-operative assessment and Emend prescription our first 2 PONV interventions. In addition, anesthesia providers will use IV Zofran (ondansetron hydrochloride) intraoperatively in patients at a high risk for PONV, repeating the dose for cases lasting longer than 4 hours. Reglan or Phenergan (promethazine) suppositories are used as rescue drugs, when needed, in PACU.

A wave of success
We believe the key to the success of our quality improvement study was the emphasis on prevention rather than treatment of post-operative nausea and vomiting. With the vast majority of our patients undergoing general anesthesia for their plastic surgery procedures, we could have a sizable percentage of patients going green around the gills in our PACU. After we implemented the PONV prevention program at our facility, about 85% to 93% of our patients reported no post-operative nausea or vomiting, either at our facility or at the time of follow-up calls 24 to 48 hours post-procedure. As of July 2009, our PONV rate was 7% overall, with no notable cases of vomiting.

By screening for high-risk patients ahead of time and intervening pre-operatively, we can be fairly confident in assuring them that the wave of nausea they might feel immediately after emerging from anesthesia will wear off quickly.