PONV Prevention Pays Off

Postoperative nausea and vomiting is the last thing patients want to deal with when they're recovering from surgery. Waking up in the PACU feeling sick can ruin any good feelings they might have had about a successful procedure and the care your team provided. PONV can also lead to concerns more serious than satisfaction scores: prolonged post-op stays, unanticipated hospital admissions, wound dehiscence, aspiration, esophageal ?tears, electrolyte imbalance and an overall delay in a return to functional ability. Thankfully, there are several effective and economical ways to prevent PONV, especially if you're willing to think outside the box.

• Nerve blocks and antiemetics. Narcotics can cause PONV because they slow bowel function, which can lead to constipation, bloating, vomiting and ?nausea. Employing regional anesthesia, which minimizes the use of heavy narcotics and volatile anesthetics, immediately eliminates two risk factors. As a result, patients will have shorter recoveries, experience less pain and have little to no nausea.

Anesthesia providers play an important role in preventing PONV, because they can employ regional blocks before surgery begins. They might also administer antiemetics — metoclopramide, cyclizine, prochlorperazine, droperidol, ondansetron or dexamethasone — prior to and during surgery, especially to patients who present with risk factors associated with PONV.

• Aromatherapy. For many years, nurses would place an alcohol swab under the nose of a recovering patient who was nauseous in an effort to relieve the queasy feeling, but sweeter smelling options are now available. Aromatherapy's exact mechanism of action on the prevention of PONV is unknown, but it impacts the olfactory bulb, where impulses are processed and transmitted to the limbic system of the brain, and then to the central nervous system.

Before adding aromatherapy to our PONV-prevention protocols, we decided to test its effectiveness on more than 300 patients. When patients arrived in PACU, they were asked to rate their nausea from 0 to 10, with 10 being the worst. After three to five minutes of using aromatherapy inhalers, patients were asked to again rate their nausea. The average pre-intervention score was 6.11; the average post-intervention score was reduced to 2.82. We also found that 37% of patients who were treated with aromatherapy did not need any additional treatment. In fact, we also saw a significant reduction in the use of antiemetics prescribed because of aromatherapy. In three months, we were able to save 43 doses of promethazine and 34 doses of ondansetron.

Now, if a patient wakes up feeling nauseous, we ask them if they would like to try aromatherapy and have found that many are willing. We lay the aromatherapy inhaler on the chests of patients who are still groggy from surgery, but more alert patients can hold it right up to their noses and breathe in the scent.

Patients are aware of alternative therapies and are interested in what they offer.

The inhaler is a blend of four pure and natural essential oils — lavender, peppermint, ginger and spearmint — all of which are known to have therapeutic effects on nausea. Some of the perks of the aromatherapy inhalers are that they're disposable and the scent lasts for up to two hours. The cost per inhaler is only about $2. Nausea is one of those tricky things to treat because it comes and goes, but the convenience of the inhaler lets patients take it home with them once they're discharged to use again if they start to feel queasy.

• Acupressure. This ancient healing art based on the traditional Chinese medicine can help relieve tension and nausea. Acupressure bands are popular with pregnant women, especially early in their pregnancies. The bands apply pressure to the pericardium 6 (PC6) point near the wrist and can provide comparable effects to traditional antiemetics that are used in PONV prevention.
• Relaxing sounds. Music has the ability to improve the body's immune system function and reduce stress. Patients who listen to music perceive their PACU experience as significantly more pleasant than the patients who do not listen to music and report significantly less pain and less distress. We play soft music in the recovery room and patients often tell me it's very soothing.

Depending on your patient's total number of risk factors, the occurrence of PONV can be as high as 87%. Research has shown women, nonsmokers, and patients who are administered volatile anesthetics and post-op opioids are at increased risk. Abdominal surgery is another risk factor because surgeons are working near nerves of the stomach. The high incidence of PONV following open abdominal or intra-abdominal laparoscopic surgery may be due to the release of serotonin, also known as 5-hydroxytryptamine (5-HT). It plays a key role in the development of PONV in many situations, because close to 90% of the body's ?serotonin ?is made in the digestive tract.

Patients are aware of alternative therapies and are interested in what they offer. The great thing about using these therapies to manage PONV risk factors is they're easy to administer and inexpensive. They're a great way to give your nursing staff more autonomy, which promotes better patient outcomes. It is important to educate your staff and to let them witness the effectiveness of these treatments. If they can see that they are beneficial to the patient, they'll be more receptive to adding them to their repertoire. OSM