Keep PONV Under Control

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It takes a multipronged, proactive strategy and a collaborative approach.

There are no shortage of reasons to make preventing postoperative nausea and vomiting (PONV) a top priority, as this problematic complication often prolongs a patient’s stay, increasing financial strain and destroying patient satisfaction.

The incidence of PONV range — 30 percent in the general surgical population to as much as 80 percent in high-risk patients — emphasizes how critical it is for hospitals and surgery centers to implement a proactive multimodal strategy designed to keep PONV at bay.

Control through collaboration

It takes a collaborative approach among surgeons, nurses and anesthetists to make that happen. Here are some tips on how to do it:

• Assess risk factors. This can be divided into four areas: patient risk factors, medical history, type of anesthesia being used for surgery and type of surgery being performed. The Apfel Simplified Risk Score is easy for organizations to use. It assesses patient risk for PONV on four factors: female gender, non-smoking status, history of motion sickness or PONV and postoperative opioid use. A patient with more than two of those factors is considered high-risk. When comparing male vs. female for risk factors, females are at a significantly higher risk for PONV and current data suggests the reason is hormonal susceptibility. So a female who doesn’t smoke and is getting opioids for pain is already at high risk for PONV.

• Understand prevention vs. rescue. To better understand PONV, it can be split into two groups: prophylaxis, a medicine or course of action to prevent PONV prior to surgery; and rescue, which is treatment after surgery. “In an ideal world, you’d never need rescue treatment because you’d already used the preventative medications, and it helped the patient completely,” says Jawad Saleh, PharmB, PharmD, BCPS, BCCCP, MCSO, clinical manager of pharmacy services at Hospital for Special Surgery in New York City. “But that’s in an ideal world.”

Start reducing the risk by using techniques that are less likely to be associated with PONV.
Ashraf S. Habib, MD, MBBCh, MSc, MHSc, FRCA

According to Dr. Saleh, an arsenal of medications can be used to prevent PONV. The most common, based on efficacy and cost, is ondansetron, which works by blocking the action of serotonin, a natural substance that may cause nausea and vomiting. It’s one of the 5-HT3 receptor antagonists, a class of medications used in the prevention and treatment of PONV. “It’s inexpensive, it’s efficacious and it’s been studied and used for years,” says Dr. Saleh. He adds that if a patient has two of the risk factors, then the medical staff should use two agents. For every additional risk factor, an additional agent should used for prevention. “It would be really beneficial for organizations to have an alert in their electronic medical record, or whatever computerized system they are using, to alert the staff that this patient has three or more risk factors,” says Dr. Saleh.

Other solutions include using standardized forms or checklists to ensure the care team is on the same page and aware of the preventative steps they must take.

Employ different techniques. Prevention comes with its own challenges, though, according to Ashraf S. Habib, MD, MBBCh, MSc, MHSc, FRCA, chief of the Division of Women’s Anesthesia at Duke University School of Medicine in Durham, N.C. “Start reducing the risk by using techniques that are less likely to be associated with PONV,” says Dr. Habib. For example, he suggests minimizing the use of inhaled agents like nitrous oxide on the patient, and by using an opioid-sparing strategy.

“And if the patient’s surgery is amenable to using a regional technique, this has been shown to be associated with significant less risk of PONV compared to using a general anesthetic technique,” says Dr. Habib.

Once the patient gets to the PACU, there are a number of antiemetics (drugs used to ease nausea and vomiting) that can be deemed appropriate to use on them if needed during the rescue stage.

“You give the antiemetics that work on different receptors. You don’t give two agents that work on the same receptor. The patient won’t get any additional benefit,” says Dr. Habib. “You pick an agent that works on one receptor and then combine it with another agent or two or three that work on different receptors.”

When an agent for treatment has been selected, it needs to be for a different receptor, it needs to be an agent that works quickly, and it should not been given within the previous four to six hours, says Dr. Habib.

• Practice strategic timing. Consider how quickly the medications work and how long it takes them to be effective when given at the right time. For example, dexamethasone (a corticosteroid) is given at induction while ondansetron would be given at the end of induction because of the time they take to be effective.

“When talking about rescue, or treatment, timing is key. You don’t have the luxury of preparing,” says Dr. Saleh. “If someone is nauseous or vomiting, the scopolamine patch (which is placed behind the patient’s ear that has little or no hair, takes up four hours to work and is left in place three days after surgery) can’t be given. You need something that works right away.” He adds that typically during a rescue, patients shouldn’t get the medications orally. “How could someone swallow while they are vomiting? If you take an oral medication, it will take about an hour to work. You’d like to give IV pushes straight into the system,” says Dr. Saleh.

Alternative treatments

acupuncture
THAT’S THE SPOT Activation of the P6 acupuncture point — located between the two tendons on the patient’s wrist — is an effective alternative treatment for easing nausea and staving off PONV.

When it comes to non-drug treatments for PONV, there are several effective options, including:

• Acupuncture. According to Dr. Habib, the data on the efficacy of acupuncture for PONV is as good as the data for any other antiemetic. “In practice, though, it is very tough. The expertise in it is limited. I’ve done studies on it before, but when it comes to applying it in practice, it’s unfortunately not commonly used,” he says.

The technique involves what is called the P6 acupuncture point, which is between two tendons on the patient’s wrist. When that point is stimulated, it’s very effective in easing nausea. “You will see thousands of potential applications for acupuncture, but the one for PONV has been well-documented, well-researched and well-confirmed. It is definitely an effective modality,” says Dr. Habib.

• Aromatherapy. According to Dr. Saleh, aromatherapy is inexpensive and easy to use. Isopropyl alcohol, peppermint and lavender are the most promising ingredients to use according to current data. “With aromatherapy it has be unit-dosed, and you have to make sure the patient in the bed next to them can’t smell it,” says Dr. Saleh. “At times there could be an allergy issue or a satisfaction issue when other patients don’t like the smell.”

Dr. Habib agrees. “It doesn’t have any side effects and it’s easy to implement. If it helps, it helps. There are no great studies investigating it, but it is harmless,” he says.

• Chewing gum. Using chewing gum to ease PONV has actually shown some promising results, according to Dr. Habib.

“There is a much larger study that is currently under way, but [based on] the limited data we have, it seems like chewing gum might be helpful,” he says.

Not so with music therapy. “I don’t think it has been shown to be effective,” says Dr. Habib.

Stay diligent

PONV can be more than a bedside issue. Length of stay due to PONV could be a financial burden and patient satisfaction scores can plummet if PONV is not effectively controlled. And generally, preventing PONV can be easier than treating it.

According to Dr. Saleh, there is data that show patients would rather deal with the pain than with the nausea and vomiting.

“Depending on the type of surgery, you can have postoperative complications. You can’t leave if you’re vomiting,” he says. OSM

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