TO THE RESCUE Jeffrey R. Darna, APN, ACNP-BC, CRNA, relies on multimodal interventions to prevent PONV.

Post-operative nausea and vomiting is an old but ongoing clinical problem, a bane to nearly every outpatient surgical facility. About 5 years ago, we at Short Hills Surgery Center set out to reduce our PONV rate. The results have been nothing short of amazing.

It's not as though our PACU was full of nauseated patients. Our PONV rates were already very low, between 1% and 2%. But with PONV, even 1 incidence is 1 too many — both for the unfortunate patient whose recovery is needlessly delayed and for the recovery room nurse whose day just got a lot more difficult. We were doing well, but we knew that we could better our patients' experiences if we studied the evidence on ways to prevent and ameliorate nausea and vomiting after surgery.

Multimodal interventions
We first studied the ample literature to understand the science of PONV prevention. We decided we'd identify at-risk patients through a detailed history. We'd then risk-stratify those patients and aggressively prevent PONV in moderate- and high-risk patients. Our protocol:

1. Assess the patient for a history of PONV (and severity) and/or motion sickness.
2. Patients who report PONV and motion sickness receive pre-operative meclizine 25mg PO.
3. Operative management includes total intravenous anesthesia with propofol, dexamethasone (unless contraindicated), ondansetron, metoclopramide and a short-acting narcotic.
4. Minimize the amount of narcotics and opt for such alternative pain management strategies as NSAIDs, nerve blocks and local anesthetics.
5. Adequate IV hydration.
6. PACU rescue anti-emetics are either trimethobenzamide or promethazine.
7. For known severe, refractory PONV, we might add pre-op sea bands and intraop droperidol IV.

It might seem like we're giving patients a lot of medication, but only moderate- to high-risk patients receive the entire cocktail, and we customize the plan of care for each patient. Remember that PONV is a complex phenomenon that's often prevented and ameliorated using a multimodal approach that shuts down a multitude of pathways that contribute to it. As a result of our intervention, PONV incidents are rare and nearly undetectable in the 7,500 procedures we perform annually. Our success results from

• appropriate screening and risk stratification;
• avoiding such known PONV triggers as inhalation agents; and
• multiple receptor and PONV pathway alteration.

Thankfully, all of the drugs that we use are low-cost generic formulations. But just think of the cost of the delayed discharges that we're avoiding. Besides occupying a stretcher in our recovery room, a nauseated patient occupies our nurses' time as well.

Keys to successful implementation
Here are a few keys to success with this protocol.

• Buy-in from stakeholders. Like most things in surgery, this protocol requires collaboration and buy-in among anesthesia, administration and the nursing staff. Otherwise, people will revert back to old styles of practice and leave your evidence-based protocol behind.
• Strong educational foundation. From the nurse making pre-op phone calls to the discharge RN, make sure everyone who influences patients fully understands your protocol.
• Limit exposures to offending agents. It's not enough to stratify a patient's risk; you have to modify the anesthetic as well. You can't maintain high-risk patients on an offending inhalational agent.

Reader Survey

Which best describes your feelings about aromatherapy for treating PONV?

It's shown promise as rescue therapy for PONV.	32%
We've tried aromatherapy devices on our patients, but they didn't do much.	16%
We're satisfied with traditional anti-emetics.	21%
We've never used aromatherapy devices, but would like to trial them.	31%

Source: Outpatient Surgery Magazine InstaPoll,
September 2012, n=189