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Anesthesia Alert
The Recipe for Preventing PONV
, Elizabeth Edel, John Frenzel
Publish Date: October 10, 2007   |  Tags:   Anesthesia

There's no magic bullet to eliminate post-op nausea and vomiting, but there's plenty we can do to prevent it. Our anesthesia and nursing teams reduced our incidence of PONV from 18 percent to 3 percent. Here's how we did it.

1. Determine your PONV baseline. Examine the rate of PONV incidence by provider and by provider practices in drug selection, dosage and timing. We found our PONV rate was 18 percent, but more importantly we learned how providers with the lowest rates picked and used their therapies.

2. Create a protocol reflecting the best practices. Combine what those providers who have the lowest PONV rates do with evidence-based research to create a prophylaxis and treatment protocol reflecting the best practices.

3. Implement, then modify. Put your best practices to work and evaluate their results by monitoring patient outcomes over a nine-month period. Periodically review the data and the protocols with the team, talking over what worked and what didn't and initiating some new practices. Go into this project knowing that it will be a work in progress. It took us 12 cycles over 22 weeks to arrive at our current regimen, which you can see below. Since implementing this system, our PONV rate has dropped from 18 percent to 3.2 percent. It has stayed at this level for more than a year. Co-incidentally (or perhaps not), the cost of our PONV regimen has dropped by more than 40 percent.

4. Make the new protocols easy to follow. Create a flow sheet to serve as a decision tree for PACU PONV management. Analyze the entire patient encounter and account for each step of the process, from the pre-op evaluation to the day after discharge. It will take the sum of all of these adjustments, each suggested and implemented by a different member of your team, to reduce your rates.

From Holding to PACU, Our Secret PONV Formula

  • In the holding area, we updated the patient pre-op assessment. The nurse asks about and identifies risk factors for PONV, which means finding out if the patients are female; non-smokers; have had a history of PONV or of motion sickness; and are expected to receive post-op narcotics.
  • Patients identified pre-operatively as being at a high PONV risk receive a scopolamine patch in addition to standard treatment.
  • Intraoperatively, the administered PONV prophylaxis includes dexamethasone 10mg after induction. We administer ondansetron 4mg and promethazine 6mg just before extubation.
  • In the PACU, we treat PONV with a granisetron 1mg IV push over 30 seconds for one dose. If this is ineffective, we give promethazine 6.25mg IV push over 30 seconds or ondansetron 4mg IV push over 30 seconds. We don't give more than two doses of either promethazine or ondansetron over a four-hour period.
  • In the PACU, an anesthesiologist is always overseeing our patients. He is immediately available for patient consultation and to address any changes in patient condition. This is also the person who is notified if the PONV protocol isn't effective and who considers what interventions to try next.
  • Twenty-four hours after discharge, we contact all patients to determine their physical status and to solicit feedback on their recovery. We use this opportunity to follow up on the efficacy of our PONV regimen. We electronically document all of the patient interventions and outcomes to improve statistical analysis.

- Elizabeth Edel, RN, and John Frenzel, MD

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