NOTHING'S WORSE Nearly one-fourth (24%) of surgical patients dread post-operative nausea and vomiting more than post-op pain or the IV start, according to the 313 readers Outpatient Surgery surveyed last month.

A case of post-operative nausea and vomiting is bound to leave a bad taste in a patient's mouth, proverbially speaking, even if her surgery is a complete success. From my experience, patients rank PONV as one of the most distressing aftereffects of surgery, even more so than post-operative pain. That's why I consider preventing PONV my No. 1 priority apart from preserving the patient's safety and comfort during the surgery. Here's my 5-point plan designed to make sure patients get discharged with their stomachs settled — and your facility's reputation intact.

1 Know your patient. PONV affects as many as 40% of patients. Preventing it is all about ameliorating the risk based on the patient's history, the nature of the surgery and gender. Young women are more prone to PONV — as much as 3 times more likely than men, in fact. Nonsmokers and anyone with a history of migraines or motion sickness tend to be more at risk, too.

Ask patients if they have a history of PONV, but some patients might not remember or might not even know that they're prone to PONV. So do some legwork on the patient to see if you can learn more. You'll learn more when you speak with the patient directly, so use your pre-operative introduction as an opportunity to uncover more information. When I contact a patient the night before surgery, I'll answer any questions they might have and also ask a few of my own so I can complete a formal assessment to gauge the likelihood of PONV. If the patient is anxious and has a history of PONV, administer an antiemetic like aprepitant or ondansetron. I'll also remind the patient of NPO fasting guidelines, but if their case is later in the day I'll encourage them to take some PO water or, if they have reason to think they might suffer from withdrawal, some coffee.

2 Know the risks associated with the surgery. As a general rule, the longer the surgery, the higher the risk of PONV, though some surgeries by their very nature are more likely to trigger PONV. GYN surgery, like a bilateral tubal ligation, or a breast surgery, or anything that manipulates the equilibrium centers, like an inner-ear surgery or an eye-muscle surgery, or pretty much any kind of plastic surgery — all of these will expose the patient to a higher PONV risk.

IN THE SPOTLIGHT
Dr. Ma Shines on Reality TV Shows Survivor and Shark Tank

CASTAWAY Dr. Ma on Survivor: South Pacific. BIG FISH Dr. Ma on Shark Tank.

Chances are you've seen anesthesiologist Edna Ma's face before. She was one of 18 castaways competing for the $1 million purse on CBS's long-running reality show Survivor: South Pacific. She spent 33 days on the island of Upolu, Samoa, and outlasted all but 6 of her fellow castaways. Two years later, she appeared on ABC's Shark Tank. There she promoted Dr. Edna's BareEASE, the skin anesthetizer and moisturizer she dreamed up after receiving her first "needlessly painful" Brazilian bikini wax. Her inspiration (osmag.net/7YbRNj) came in part from EMLA cream, the local anesthetic.

— Bill Donahue

3 Avoid volatile anesthetics. Unless someone who has a personal history of nausea and vomiting tells you upfront, "Yes, I'm going to have a problem," there's no tried-and-true way to predict when PONV will be an issue. But using volatile anesthetics, including nitrous oxide, is sure to ratchet up the risk. So when and if you can avoid volatile anesthetics, ask yourself: What is a safe alternative? Whenever possible, I'd suggest using a propofol infusion in their place. Other considerations: Is regional anesthesia or neuroaxial anesthesia an option, given the nature of the procedure? Also, using opioids to manage a patient's pain can trigger PONV, so can we use a transverse abdominis plane block or interscalene block to minimize the use of post-op opioids?

4 Have a game-day game plan. Here's my day-of-surgery approach to PONV prevention:

• Providing IV hydration early will help avoid dehydration. This will prevent nausea, but it can also ensure that the patient gets back on her feet quickly. As long as there's no contraindication, I'll give 20 mL per kilo of an isotonic lactate solution like Ringer's or Plasma-Lyte. Avoiding normal saline solution helps prevent hyperchloremic metabolic acidosis.
• A scopolamine transdermal patch may be appropriate for anybody who has a history of nausea and vomiting but who isn't prone toward dementia, because it can cause post-operative confusion. Also, it takes some time for the body to absorb the scopolamine, so it's not a good option for procedures that last less than 2 or 3 hours.
• If a muscle relaxant is needed, I dose appropriately to minimize the need for reversal, because neuromuscular blockade reversal agents like neostigmine and glycopyrrolate are known to cause nausea.
• As long as there is no contraindication, consider a multi-receptor approach using a number of antiemetic interventions: aprepitant, which is a selective high-affinity antagonist of human substance neurokinin 1 (NK1) receptors; metoclopramide, which has antagonist activity at D2 receptors in the chemoreceptor trigger zone in the central nervous system; ondansetron, which is an antagonist to serotonin receptors of the 5-HT3 type; and dexamethasone, which is believed to work in the chemoreceptor trigger zone of the brain stem.

There are a couple of important points worth noting that might affect your decisions regarding whether or not to use a multi-receptor approach: Metoclopramide is contraindicated in Parkinson's disease, as it may worsen a patient's symptoms. In addition, metoclopramide may cause extrapyramidal side effects that can make patients feel anxious, especially if those patients are already prone to anxiety.

• Don't forget the non-opioid analgesics — NSAIDs, such as ketorolac, and acetaminophen, which is now available in IV form. Used individually or combined, they are great for further reducing pain, while avoiding nausea-provoking opioids.

NATURE CALLS
All-Natural Nausea Relief

COMPLEMENTARY Aromatherapy represents an alternative and complementary therapy for management of PONV.

Can non-pharmacological modalities like aromatherapy, acupressure and acupuncture help stave off post-operative nausea and vomiting?

Aromatherapy. Madigan Healthcare System conducted a study comparing the effectiveness of an aromatherapy inhaler to placebo for relief of PONV. Most aromatherapy patients showed a statistically significant decrease in nausea, as well as a significantly higher perception of treatment effectiveness. Another study found aromatherapy to be an effective self-care strategy at decreasing post-discharge nausea.

Acupressure. Brandon (Fla.) Regional Hospital reported promising results in a clinical trial of an acupressure wristband infused with peppermint aromatherapy used to moderate PONV in endoscopy patients (osmag.net/8ZRegA). The trial concluded that the combination of aromatherapy and acupressure could be a "safe, cost-effective and efficacious" approach to decreasing instances of PONV — pre-op, post-op and 24 hours after discharge. Of the 200 patients studied, those who were given a properly placed aromatherapy-infused acupressure wristband — on the P6 acupressure point, which is located about 3 finger widths below the hand-wrist crease, in the depression between the tendons — experienced 59% fewer instances of post-op nausea and nearly 91% fewer instances of post-op vomiting, compared with patients who were given neither.

— Bill Donahue

5 Follow up. PONV prevention doesn't stop when the patient is discharged. I'll monitor patients for 24 hours after surgery to see how they're faring. Although most cases of PONV last 1 to 2 days, lingering cases of 5 days — even longer — are not unheard of. Extended cases of PONV can lead to other problems, like dehydration, pulmonary aspiration and electrolyte imbalance, so I give all of my patients my cell phone number. OSM