A Planning Playbook for Opening a New Orthopedic ASC
The ASC market continues its rapid growth. In 2023, roughly 116 new ASCs opened in the U.S., many of which were orthopedic-specific in nature....
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By: OSD Staff
Published: 10/10/2007
PONV prophylaxis strategies vary widely, in part because PONV is a complex and sometimes unpredictable event. There are also numerous 'treatment' options, which further complicates decision-making. Still, researchers have produced some solid evidence that can guide practitioners in making sound decisions when it comes to PONV prophylaxis. Essentially, there are three steps to ensuring the most clinically and cost-effective approach: Target at-risk patients, reduce baseline risk and prescribe the most appropriate antiemetic therapy for the clinical need.
Step One:
Target At-Risk Patients
Outpatient practitioners often err on the side of prevention, and for good reason. PONV can cost outpatient facilities in both dollars and patient satisfaction scores. In office surgical suites in particular, where nursing labor costs are not as fixed as they are in the inpatient environment, a prolonged PACU stay can affect the bottom line. Still, research clearly shows that an "across-the-board" approach to PONV prevention results in overprescribing of prophylactic antiemetics - a practice that is neither clinically nor cost-effective. Antiemetics can cause side effects that hinder recovery.
The first step, then, in defining a PONV prophylaxis strategy is to determine which patients are most likely to develop PONV. This is not always easy because there are numerous considerations - including patient, surgical and anesthetic factors, each which confers a different degree of risk.
Current research shows, however, that the following factors place patients at high risk for PONV: History of PONV and/or motion sickness, preoperative nausea and vomiting, young female, ENT procedures, laparoscopy procedures, major breast surgeries, plastic surgeries, shoulder procedures and strabismus surgeries. Other factors that tend to confer a lesser risk but deserve consideration include: Age less than 50 years, ASA status, nonsmoker, dehydration, anxiety, obesity, pain, gynecologic procedures, intra-abdominal procedures, oral surgery, procedures lasting more than one hour and intra- and post-op opioid use.
Step Two:
Reduce Baseline Risk
For all patients with a high risk, the practitioner can take steps during surgery to minimize PONV. These include:
Step Three:
Select Appropriate Antiemetic Therapies
For high-risk patients and for patients in whom vomiting may endanger health, prophylaxis therapy is warranted. Current therapies include pharmacotherapy and acupuncture.
In the outpatient setting, a 5-HT3 (serotonin) receptor antagonist (ondansetron, granisetron, or dolasetron) is often the cornerstone of the prophylactic drug regimen. These agents are minimally sedative, have relatively few side effects (headache and constipation are most common), and have a fast onset of action (15 to 20 minutes) when administered intravenously. Although they have different pharmacokinetic properties, chemical structures, effective doses and potencies, the three 5-HT3 receptor antagonists appear to perform very similarly for preventing PONV. A recent literature review showed that, when used prophylactically, 5-HT3 antagonists reduced the incidence of PONV by 46 percent.5 Given their similarities, drug cost is an important factor when determining which 5-HT3 antagonist to use.
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For high-risk adults who require multimodal drug prophylaxis, single doses of dexamethasone 4 to 8 mg or droperidol >1 mg work well as adjunctive agents. Research indicates that these agents, when used with a 5-HT3 receptor antagonist, can produce response rates of 90 percent or more. Given the recent concern that droperidol may be associated with extra-pyramidal side effects, however, I reserve this agent for PONV treatment when preventive measures fail. It is also wise to limit dexamethasone use to a single, minimally effective dose to avoid the side effects associated with longer-term use (wound healing problems, problems with glucose control, avascular necrosis of the femoral head).
Two other agents - cyclizine (an antihistamine that is not available in the United States) and metoclopramide (a dopamine antagonist in the same class as droperidol) - are effective for PONV prophylaxis. Research suggests that cyclizine 50 mg IV is as effective as ondansetron 4 mg IV for PONV prevention, is significantly less expensive, and may act synergistically with the 5-HT3 receptor antagonists to inhibit PONV better than 5-HT3 receptor antagonist monotherapy. However, it is associated with drowsiness, sedation, blurred vision, and dry mouth - all of which are important considerations in the outpatient setting. Other antihistamines available in the United States include dimenhydrinate and diphehydramine There appears to be little use for metoclopramide, as studies generally indicate that it is ineffective for PONV prophylaxis.
The importance of prevention
About 30 percent of surgical patients experience PONV, and patients say they are more compromised by PONV than by postoperative pain. Smart prophylaxis can be both cost- and clinically effective, leading to complete symptom control in over 95 percent of high-risk patients.
The key to success is defining which patients are at risk, reducing their baseline risk, and prescribing effective and safe preventive therapies.
References
1. Wennstrom B, Reinsfelt B. Rectally administered diclofenac (Voltaren) reduces vomiting compared with opioid (morphine) after strabismus surgery in children. Acta Anaesthesiol Scand. 2002;46(4):430-4.
2. Gupta A, Axelsson K, Allvin R, et al. Postoperative pain following knee arthroscopy: The effects of intra-articular ketorolac and/or morphine. Reg Anesth Pain Med. 1999;24(3):225-30.
3. Andersen R, Krohg K. Pain as a major cause of postoperative nausea. Can Anaesth Soc J. 1976;23:366-69.
4. Dershwitz M, Michalowski P, Chang Y, Rosow CE, Conlay LA. Postoperative nausea and vomiting after total intravenous anesthesia with propofol and remifentanil or alfentanil: How important is the opioid? J Clin Anesth. 2002;14(4):275-8.
5. Loewen PS, Marra CA, Zed PJ. 5-HT3 receptor antagonists vs traditional agents for the prophylaxis of postoperative nausea and vomiting. Can J Anaesth. 2000;47(10):1008-18.
6. White PF, Issioui T, Hu J, et al. Comparative efficacy of acustimulation (ReliefBand) versus ondansetron (Zofran) in combination with droperidol for preventing nausea and vomiting. Anesthesiology. 2002;97(5):1075-81.
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