PONV Prevention Boosts Patient Satisfaction

Patient Experience

By: Ryan Wade

Published: 3/9/2021

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Efforts to eliminate that queasy feeling improve the quality of care you provide.


TOUGH TO STOMACH Patients will remember feeling sick long after surgery, regardless of how well the procedure went.   |  Pamela Bevelhymer

My career as a nurse anesthetist recently began at two plastic surgery centers, where I knew I'd face significant challenges in managing PONV. Rates of the relatively common complication are often much higher after plastics cases (35% to 40%) than after other types of procedures (25% to 30%). Instead of waiting to treat nauseous patients postoperatively, I went on the offensive by using a personal protocol that produced immediate positive results (see "A Proactive Approach to PONV Prevention").

Incidence of PONV among my patients has noticeably declined and PACU nurses report that patients feel better, faster. As a result, patient satisfaction at the surgery centers has significantly improved. I've found out from firsthand experience that it's important to prevent PONV, not treat it. Doing so requires a perioperative strategy that will achieve optimal outcomes for happier patients.

Understand the risks

Your first step in preventing PONV is identifying patients who are most at risk. Generally, women, specifically younger women, are at higher risk, as are non-smokers and anyone with a known history of PONV or motion sickness. The type and duration of the procedure also plays a key role in the likelihood of a patient developing PONV. Intraabdominal or gynecologic procedures are believed to cause more vomiting and nausea than other surgeries.

RECIPE FOR RELIEF
A Proactive Approach to PONV Prevention
SKIN TREATMENT Placing a scopolamine patch behind a patient's ear before surgery can help prevent nausea and vomiting.

I developed the following protocol to treat PONV preemptively. It's worked well for me, so I'm passing along the specifics if you want to give it a try at your facility.

  • Begin with the basics. Standard intraoperative antiemetic prophylaxis (barring contraindications) consists of dexamethasone (Decadron) 10mg IV at induction followed by diphenhydramine (Benadryl) 25mg IV. I do this prior to the incision so each of these medications can work on their respective areas before the patent experiences the physiologic response of surgical stimulation. I also chose dexamethasone because of its anti-inflammatory properties, particularly for the airway. Because a sizable portion of my cases involve breathing tubes, I want to cut back on issues with airway swelling from manipulation of the tracheal structures during laryngoscopy.
  • Apply the patch. Patients with known risk factors or history of PONV receive a scopolamine patch placed behind their ear before surgery. One center that I work for will prescribe this patch in advance of the case, so the patient can apply it before arrival. The other center has them available on an as-needed basis.

The patch is extremely helpful with high-risk PONV patients, because it can be applied prior to surgery and kept on for three days. If treatment is needed for longer than three days to help prevent nausea and vomiting, patients can simply remove the current patch and apply a new patch behind the other ear.

  • Rescue in recovery. In the PACU, patients who experience PONV receive ondansetron (Zofran) 4mg IV. I only use this as a rescue drug, because it works differently than my intraoperative medications. Since implementing this protocol, I've received only one call from a PACU nurse requesting a one-time administration of ondansetron. That patient underwent bilateral mastectomy under general anesthesia.

Another effective option in a preemptive approach to PONV prevention is aromatherapy. I've had some experience using it as a bedside nurse, and it has helped decrease post-op nausea. Nurses can place an alcohol swab under the nose of a recovering patient who's nauseous in a pinch, but the aromatherapy inhalers offer a blend of four pure and natural essential oils — lavender, peppermint, ginger and spearmint ?— that can have therapeutic effects on nausea.

— Ryan Wade, CRNA

Lengthier procedures lead to longer exposure to anesthesia gases, and volatile anesthetics and nitrous oxide can cause nausea. Of course, when the surgeries are extensive and painful, it's critical for the anesthesia provider to adequately control pain. The analgesic approach plays a role here. Opioids increase a patient's risk of experiencing PONV, and with larger cases, opioid use can be quite high if other multimodal methods are not utilized to optimal effect.

Any procedures involving opioids are known to cause nausea and vomiting, and they can also delay gastric motility. Your anesthesia providers should look to collaborate with surgeons whenever possible to determine local anesthetic options that can further decrease opioid use and lessen the risk of PONV. For instance, I frequently use IV versions of acetaminophen or ibuprofen prior to surgery. If these options are unavailable, I use the appropriate oral dose.

PONV is not only a patient satisfaction issue; it's safer in the long run for your patients to have controlled nausea. Straining from vomiting can tear sutures, which can lead to bleeding, return trips to the OR or even infection. For plastics procedures such as tummy tucks, straining is deleterious to the sutures used to join abdominal muscle and close the large incisions. You also don't want a patient who just underwent a complex abdominal surgery to start vomiting or bearing down, because they can rupture the sutures in their long and vulnerable incision.

Setting realistic expectations with patients about how they'll feel after surgery alleviates their anxiety and lets them know you're personally vested in their care. I'm upfront and honest with mine in discussing anticipated pain levels and nausea control. Patients do expect some discomfort when they're in recovery. However, I put them at ease by letting them know I'm using all the tools at my disposal to keep them as comfortable as possible.

Sharing what works

As a former bedside nurse, I understand the challenges faced when receiving a patient experiencing inadequately controlled nausea. That's why it's important to regularly engage with PACU nurses about the effectiveness of your PONV prevention protocols.

Lengthier procedures lead to longer exposure to anesthesia gases, and volatile anesthetics and nitrous oxide can cause nausea.

They'll be fully aware of the number of patients who arrive in recovery feeling nauseous and the steps they take to ensure patients' nausea is well-controlled before discharge. Calling patients at home after surgery to see if they have any concerns regarding their PONV management adds a personal touch to their care and provides another mechanism of feedback that can help you fine tune your practices as needed.

Although neither of the facilities I work for collect data specific to incidences of PONV, I know rates are low because I keep in regular contact with the PACU nurses and patient coordinators to ensure I'm providing the highest level of care. One facility distributes patient surveys to gauge overall satisfaction with their experience. If there's an issue, we will surely know about it. That's important, because it's essential to keep your facility's word-of-mouth impact in mind. Controlling PONV not only keeps patients happy, it directly impacts the health of your business and your facility's reputation.

To continually strive for improvement in PONV prevention, talk to your anesthesia providers about their choice of antiemetics. Anesthesia professionals individualize patient care as much as possible, and keeping open communication is key to building a better understanding of what practices are effective. Ultimately, it's up to anesthesia professionals to choose the optimal PONV prevention strategy based on the needs of their patients. However, collaboration among surgical leaders, anesthesia providers, surgeons and staff ensures everyone is applying effective interventions. OSM

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