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PONV Prevention
Do everything you can to have every patient feeling fine after surgery.
Steven Gayer
Publish Date: June 18, 2014   |  Tags:   Anesthesia
PONV worse than pain BITTER MEMORY Patients who experience PONV often recall it as having been worse than the pain.

No matter how well you care for your patients; no matter how competent, caring and congenial you and your staff are; no matter how well the surgery turns out; if patients feel nauseated afterward — and especially if they find themselves vomiting — the bad taste left in their mouths is likely to linger for a long time. Ask patients what negatives they most vividly recall from their surgeries and they'll put nausea at or near the top of the list, often even higher than pain. Feeling squeamish after surgery is that potent of an experience, but it can be avoided.

1 Know who's vulnerable
It's been assumed and expected that about 30% of patients will vomit post-operatively and that many more will teeter on the brink. But obviously, having a 30% (or higher) patient dissatisfaction rate is no way to run an OR.

Fortunately, you can plan ahead to try to reduce the suffering by recognizing certain patients as high-risk and tailoring your treatment accordingly. There's no fool-proof formula when it comes to determining who's susceptible and who isn't, but not surprisingly, the strongest indicator is past experience with PONV. Also strong candidates: People who are prone to motion sickness. Females are more susceptible than males, the young are more susceptible than the elderly, and curiously, people who don't smoke are more likely to be affected than those who do.

That high levels of anxiety also make people more susceptible has generally been disproved, but that doesn't mean that anxiety-reducing drugs hold no value in the battle plan against PONV.

2 Keep an open mind
Let patients participate in PONV-prevention efforts by having them apply a scopolamine "cruise" patch behind an ear the night before the surgery. The patches have been refined and improved over the years, so they're more effective with fewer side effects.

Some patients may also arrive with acupressure wrist bands, inspired by Chinese medicine and thought to diminish PONV by putting pressure over a certain spot on the wrist. There's nothing wrong with that. Some people of science want to dismiss alternative approaches to PONV prevention, but studies show they work.

3 Hydrate and reduce anxiety
Above all, make sure patients are hydrated. The best way to do that? Don't let them become dehydrated to begin with. We've learned over the years that the old saw about having nothing to eat or drink after midnight, which may result in 10, 12 or 14 hours without eating before surgery, actually increases PONV risk. It's safe to encourage otherwise healthy patients to drink clear fluids up until 2 hours before surgery. Keep them hydrated by starting an IV in pre-op. Finally, right before surgery, I like to give susceptible patients anxiety-dampening medications, not just to calm them down, but also because benzodiazepenes, like midazolam, may have antiemetic properties.

Better PONV Treatments on the Way?

happier in post-op ALL SMILES Patients might be happier in post-op in the near future.

The science related to understanding and preventing PONV is both very interesting and very important, and I expect some new approaches to be coming down the pike shortly.

For instance, when I was in training, droperidol was considered the be-all and end-all for treating PONV. But the FDA issued a "black box warning" in 2001, because it was linked to a certain rare heart condition. It's rarely used anymore. Worth noting, however: Pharmaceutical companies are working on making a droperidol analog that doesn't contain the cardiac risk factor, so we may see that on the market soon.

Another company is working on developing a pill or a patch that uses the antiemetic properties of propofol, but alters its molecular structure so it no longer acts as an anesthetic

And now there's a second generation of the popular antiemetic drug ondansetron (Zofran) called palonosetron, which has fairly recently hit the market, and which shows promise as a PONV-prevention therapy.

Meanwhile, scientists are trying to determine whether some people have a genetic predisposition to nausea after surgery. If they can identify key genetic variations in the way people metabolize drugs or react to stressors, we should be able to do an even better job of tailoring treatments for those people.

— Steven Gayer, MD

4 Avoid opioids
Of course, the real dark villains of the PONV drama are narcotics and their evil sidekicks, volatile inhaled anesthetics. Having determined that you're working with a vulnerable patient, can you get her through surgery and out the door without using narcotics or inhalation agents? At the very least, you want to minimize your use of agents that are known to promote PONV.

Can the surgery be done with regional anesthesia? If so, you'll likely minimize the risk of PONV. If not, can you avoid inhalation agents by using propofol exclusively, via a continuous intravenous stream? Can you adequately control pain with NSAIDs or acetaminophen, thus eliminating the need for narcotics?

eating after surgery FOOD FOR THOUGHT PONV-prone patients may not feel like eating or drinking after surgery. The important thing: Don't force the issue.

5 Follow through
Stay on top of the PONV prevention plan in post-op, where often it's reflexive to order narcotics for patients who are experiencing discomfort. If staff members are aware and communicating, they can look for other ways to reduce pain without resorting to treatment that may make the patient even more miserable. There's also likely to be a temptation to want to get patients up and out quickly, but patients will respond better if you keep the IV in place and keep them hydrated.

And when it comes to eating or drinking, don't force the issue. That's something a lot of people aren't aware of. You do not want to force food or fluids on patients who are prone to PONV. Some may want to eat, but not want to drink. That's OK. Give them time. They'll eat and drink when they're ready.

The 30% or more of patients who experience PONV are a big concern for any facility that cares about patient satisfaction. Can you reduce the number to zero? That's the goal you should be striving for, whether it's actually achievable or not.