Jump to content

Postoperative nausea and vomiting

From Wikipedia, the free encyclopedia
Postoperative nausea and vomiting
SpecialtyAnesthesia

Postoperative nausea and vomiting (PONV) is the common complication of nausea, vomiting, or retching experienced by a patient within the first 24 hours following a surgical procedure. Untreated, PONV affects about 30% of patients undergoing general anesthesia each year, with rates rising to 70–80% among those considered high-risk.[1] PONV can be highly distressing for patients and may contribute reduced oral intake of fluids, food, and postoperative medications, surgical complications, unanticipated overnight admission (~1% of all same day surgery patients), and delayed discharge.[2]

Cause

[edit]

Risk factors

[edit]

Risk factors for PONV can be classified into three main categories: patient-related, surgical, and anesthetic-related.[3]

[edit]

Patient factors that confer increased risk for PONV include female gender, younger age (<16 years old), obesity, non-smoking status, high levels of preoperative anxiety, and prior history of PONV, motion sickness, or chemotherapy-induced nausea.

The Apfel risk-scoring system is commonly used to sensitively and specifically determine the risk of PONV in adults.[3] This simplified scoring system considers four primary predictors:

  1. Female sex (most reliable)[4]
  2. Non-smoking status
  3. History of PONV or motion sickness
  4. Post-operative opioid use

The presence of 0, 1, 2, 3, or 4 factors corresponds to PONV risks of approximately 10%, 20%, 40%, 70%, and 80%, respectively.[5]

Research has also shown a genetic disposition towards PONV. A 2008 study compared 121 Japanese patients who experienced PONV after being given the general anesthetic propofol to 790 people who were free of postoperative nausea after receiving it. Those with a G at both copies of rs1800497 were 1.6 times more likely to experience PONV within six hours of surgery compared to those with the AG or AA genotypes, but they were not significantly more likely to experience PONV more than six hours after surgery.[6]

Surgical

[edit]

Certain procedure types such as gynecological, abdominal, laparoscopic, ENT surgeries, and strabismus surgery in children are associated with a modestly increased risk of PONV versus other general surgical procedures.[3]

[edit]

Several medications routinely used in anesthesiology are believed to contribute to nausea and vomiting by acting on the highly sensitive chemoreceptor trigger zone (CTZ) located in the area postrema in the medulla oblangata, although the exact mechanisms remain poorly understood. Prolonged exposure to these drugs, namely volatile anesthetics, nitrous oxide (N2O), physostigmine, and opioids has been found to be correlated with increased PONV risk.[3][7]

A significant body of evidence indicates that total intravenous anesthesia (TIVA) using propofol for induction and maintenance can reduce the incidence of PONV 3.5-fold in adults and 5.7-fold in children in comparison to volatile-anesthetic based techniques.[3][8] Regional anesthesia has also demonstrated better outcomes for patients when compared to its general counterpart.

Mechanism

[edit]

The pathophysiology of PONV is mediated by several key neurotransmitters, including histamine, dopamine, serotonin, acetylcholine, and the more recently recognized neurokinin-1 (substance P). Pharmacologic stimulation of different chemoreceptors in the brain trigger different pathways that can result in PONV. Additionally, direct surgical manipulation of the vestibular system (cranial nerve VIII) or gastrointestinal structures innervated by the vagus nerve (cranial nerve X) can further activate the neural pathways involved in precipitating nausea and vomiting.

Prevention

[edit]

According to the Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting, key strategies in the prevention of PONV include diligent risk assessment and stratification, use of non-volatile anesthetic techniques when feasible, provision of prophylaxis based on risk, and employment of multimodal, opioid-sparing techniques for perioperative pain control.[9]

Optimizing intravascular fluid volume during surgery is another strategy to reduce the risk of PONV, often achieved by administering additional IV fluids under general anesthesia.[2][3] This approach addresses the fluid deficit caused by preoperative fasting, which typically restricts oral fluid intake for 2–6 hours before surgery. Notably, a large retrospective analysis performed in Torbay Hospital found that allowing unrestricted intake of clear fluids up until transfer to the operating room significantly reduced the incidence of PONV, without increasing the risk of adverse outcomes for which such conservative guidance exists.[10] For minor surgical procedures, more research is needed to determine the risks and benefits of this approach.[2]

Management

[edit]

Commonly administered medications like serotonin receptor antagonists (ondansetron), corticosteroids (dexamethasone), and neurokinin-1 receptor antagonists (aprepitant) primarily act by modifying the release and activity of the aforementioned neurotransmitters involved in nausea and vomiting, effectively reducing the incidence of PONV. Using a multimodal approach by combining drugs targeting different receptors involved in PONV has been shown to be more efficacious than monotherapy.[11] However, numerous patient factors, adverse side effects, and cost-effectiveness of these medications must be taken into consideration when selecting a treatment regimen. Recent evidence has shown that alternative therapies may also play a role in decreasing the incidence of PONV when used in conjunction with conventional treatment.[12]

Medications[13]

[edit]
  • Serotonin (5-HT3) receptor antagonists can be administered as a single dose at the end of surgery. Adverse effects include prolongation of the QT interval on electrocardiogram (EKG). Medications include ondansetron, granisetron, and dolasetron.
  • Anticholinergics can be used as a long-acting patch placed behind the patient's ear. Adverse effects include dry mouth and blurry vision. Care must be taken when handling the patch, as transfer of medication to the eye can induce pupillary dilation. Avoid use in elderly patients. Medications include scopolamine.
  • Glucocorticoids have direct antiemetic effects and can reduce need for postoperative opioids. Adverse effects include a transient increase in serum glucose level, and poor wound healing (controversial). Medications include dexamethasone.
  • Butyrophenones are antipsychotic medications that are typically administered as a single injection at the end of surgery. Medications include droperidol and haloperidol, although droperidol is less frequently used as it may cause QT prolongation on EKG.[2]
  • Phenothiazines are particularly effective in treating opioid-induced PONV. Adverse effects are dose-dependent and include sedation and extrapyramidal symptoms. Medications include promethazine, chlorpromazine and prochlorperazine.
  • Neurokinin-1 (NK1) receptor antagonists prevent emetic signals from being transmitted to the area postrema. Medications include aprepitant and rolapitant.
  • Histamine receptor antagonists can be administered by multiple routes, including orally, intramuscularly, or rectally. Adverse effects include dry mouth, sedation, and urinary retention. Medications include dimenhydrinate and diphenhydramine.
  • Propofol, an anesthetic medication, confers its own antiemetic properties.

Weibel, Rücker, Eberhart et al's 2020 Cochrane review demonstrated that a combination of dexamethasone and ondansetron is the currently the most common anti-emetic therapy for PONV.[11] The review adds robust evidence towards the efficacy of drugs in newer classes, such as aprepitant or fosapreitant, or newer agents in familiar classes, such as ramosetron. The review does not cover the cost effectiveness of the agents included and, despite increased efficacy for said novel agents, this may preclude their immediate utilization in anesthetic practice.[11]

Alternative therapies

[edit]

The management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for reducing PONV incidence and achieving enhanced recovery after surgery. In addition to incorporating non-opioid analgesics like NSAIDs and acetaminophen, at least one study has found that application to the pericardium meridian 6 acupressure point produced a positive effect in relieving PONV.[14] Another study found no statistically significant difference.[15] The two general types of alternative pressure therapy are sham acupressure and the use of the P6 point. A 2015 study found no significant difference between the use of either therapy in the treatment or prevention of PONV. In a review of 59 studies, both therapies significantly affected the nausea aspect, but had no significant effect on vomiting.[citation needed]

A Cochrane systematic review and meta-analysis performed in 2022 suggests that music interventions in the perioperative period can effectively reduce postoperative vomiting, although their impact on nausea remains inconclusive.[12]

Another systematic review has shown that ginger consumption is associated with a significantly reduced incidence on PONV 6 hours after surgery when compared to placebo. However, further investigation evaluating ginger's efficacy against and with conventional anti-emetic prophylaxis is required to properly determine its use as a supplemental therapy.[16]

Cannabinoids have also been used for treatment of PONV, but its safety and efficacy are controversial.[citation needed]

Epidemiology

[edit]

Typically, the incidence of nausea or vomiting after general anesthesia ranges between 25 and 30%.[17] Nausea and vomiting can be extremely distressing for patients, and so is one of their major concerns.[18] Vomiting has been associated with major complications, such as pulmonary aspiration of gastric content, and might endanger surgical outcomes after certain procedures, for example after maxillofacial surgery with wired jaws. Nausea and vomiting can delay discharge, and about 1% of patients scheduled for day surgery require unanticipated overnight admission because of uncontrolled PONV.[citation needed]

References

[edit]
  1. ^ Amirshahi, Mehrbanoo; Behnamfar, Niaz; Badakhsh, Mahin; Rafiemanesh, Hosein; Keikhaie, KhadijeRezaie; Sheyback, Mahmood; Sari, Mahdeh (2020). "Prevalence of postoperative nausea and vomiting: A systematic review and meta-analysis". Saudi Journal of Anaesthesia. 14 (1): 48–56. doi:10.4103/sja.SJA_401_19. ISSN 1658-354X. PMC 6970369. PMID 31998020.
  2. ^ a b c d Jewer, James K; Wong, Michael J; Bird, Sally J; Habib, Ashraf S; Parker, Robin; George, Ronald B (29 March 2019). "Supplemental perioperative intravenous crystalloids for postoperative nausea and vomiting". Cochrane Database of Systematic Reviews. 2019 (4): CD012212. doi:10.1002/14651858.CD012212.pub2. PMC 6440702. PMID 30925195. S2CID 80300081.
  3. ^ a b c d e f Elvir-Lazo, Ofelia Loani; White, Paul F.; Yumul, Roya; Cruz Eng, Hillenn (2020-08-13). "Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review". F1000Research. 9: 983. doi:10.12688/f1000research.21832.1. ISSN 2046-1402. PMC 7429924. PMID 32913634.
  4. ^ Apfel, C.C.; Heidrich, F.M.; Jukar-Rao, S; Jalota, L; Hornuss, C; Whelan, R.P.; Zhang, K; Cakmakkaya, O.S. (November 2012). "Evidence-based analysis of risk factors for postoperative nausea and vomiting". British Journal of Anaesthesia. 109 (5): 742–753. doi:10.1093/bja/aes276. PMID 23035051.
  5. ^ Apfel, Christian C.; Läärä, Esa; Koivuranta, Merja; Greim, Clemens-A.; Roewer, Norbert (September 1999). "A Simplified Risk Score for Predicting Postoperative Nausea and Vomiting". Anesthesiology. 91 (3): 693–700. doi:10.1097/00000542-199909000-00022. PMID 10485781.
  6. ^ Nakagawa, Masashi; Kuri, Michioki; Kambara, Noriko; Tanigami, Hironobu; Tanaka, Hideo; Kishi, Yoshihiko; Hamajima, Nobuyuki (February 26, 2008). "Dopamine D2 receptor Taq IA polymorphism is associated with postoperative nausea and vomiting". Journal of Anesthesia. 22 (4): 397–403. doi:10.1007/s00540-008-0661-z. PMID 19011779. S2CID 19342889 – via PubMed.
  7. ^ Fernández-Guisasola, J.; Gómez-Arnau, J. I.; Cabrera, Y.; del Valle, S. García (April 2010). "Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis". Anaesthesia. 65 (4): 379–387. doi:10.1111/j.1365-2044.2010.06249.x. ISSN 0003-2409.
  8. ^ Sneyd; Carr; Byrom; Bilski (July 1998). "A meta-analysis of nausea and vomiting following maintenance of anaesthesia with propofol or inhalational agents". European Journal of Anaesthesiology. 15 (4): 433–445. doi:10.1046/j.1365-2346.1998.00319.x. ISSN 0265-0215.
  9. ^ Gan, Tong J.; Belani, Kumar G.; Bergese, Sergio; Chung, Frances; Diemunsch, Pierre; Habib, Ashraf S.; Jin, Zhaosheng; Kovac, Anthony L.; Meyer, Tricia A.; Urman, Richard D.; Apfel, Christian C.; Ayad, Sabry; Beagley, Linda; Candiotti, Keith; Englesakis, Marina (August 2020). "Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting". Anesthesia & Analgesia. 131 (2): 411–448. doi:10.1213/ANE.0000000000004833. ISSN 0003-2999.
  10. ^ McCracken, Graham C.; Montgomery, Jane (May 2018). "Postoperative nausea and vomiting after unrestricted clear fluids before day surgery: A retrospective analysis". European Journal of Anaesthesiology. 35 (5): 337–342. doi:10.1097/EJA.0000000000000760. PMID 29232253. S2CID 4486702.
  11. ^ a b c Weibel, Stephanie; Rücker, Gerta; Eberhart, Leopold HJ; Pace, Nathan L; Hartl, Hannah M; Jordan, Olivia L; Mayer, Debora; Riemer, Manuel; Schaefer, Maximilian S; Raj, Diana; Backhaus, Insa; Helf, Antonia; Schlesinger, Tobias; Kienbaum, Peter; Kranke, Peter (19 October 2020). "Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis". Cochrane Database of Systematic Reviews. 2020 (11): CD012859. doi:10.1002/14651858.CD012859.pub2. PMC 8094506. PMID 33075160.
  12. ^ a b Dursun Ergezen, Fatma; Özer, Zeynep; Kol, Emine (2022-10). "Effectiveness of Music Intervention on Postoperative Nausea and Vomiting: A Systematic Review and Meta-analysis". Journal of PeriAnesthesia Nursing. 37 (5): 717–727. doi:10.1016/j.jopan.2021.11.009. {{cite journal}}: Check date values in: |date= (help)
  13. ^ David, Vilchis-Valentin; Merith, García-Maldonado; Arturo, Larrazolo-Ochoa; Angélica, Gutiérrez-Montes Laura; Esteban, Camacho-Ramos Cesar; Cuellar-Garduño, Norma; López, Ricardo Alfonso Oropeza (2023-06-30). "Systematized review of the literature on postoperative nausea and vomiting". Journal of Anesthesia and Critical Care: Open access. 15 (3): 101–107. doi:10.15406/jaccoa.2023.15.00561.
  14. ^ Fan, Chin-Fu; Tanhui, Eduardo; Joshi, Sanjoy; Trivedi, Shivang; Hong, Yiyan; Shevde, Ketan (April 1997). "Acupressure Treatment for Prevention of Postoperative Nausea and Vomiting". Anesthesia & Analgesia. 84 (4): 821–825. doi:10.1213/00000539-199704000-00023. PMID 9085965.
  15. ^ Samad, K; Afshan, G.; Kamal, R. (February 2003). "Effect of acupressure on postoperative nausea and vomiting in laparoscopic cholecystectomy". Journal of Pakistan Medical Association. 53 (2): 68–72. PMID 12705488.
  16. ^ Zhu, Wei; Dai, Yan; Huang, Mingjun; Li, Jiping (2021-11). "Efficacy of Ginger in Preventing Postoperative Nausea and Vomiting: A Systematic Review and Meta‐Analysis". Journal of Nursing Scholarship. 53 (6): 671–679. doi:10.1111/jnu.12691. ISSN 1527-6546. {{cite journal}}: Check date values in: |date= (help)
  17. ^ Wongyingsinn, Mingkwan; Peanpanich, Pechprapa; Charoensawan, Sirirat (21 October 2022). "A randomized controlled trial comparing incidences of postoperative nausea and vomiting after laparoscopic cholecystectomy for preoperative intravenous fluid loading, ondansetron, and control groups in a regional hospital setting in a developing country". Medicine. 101 (42): e31155. doi:10.1097/MD.0000000000031155. PMC 9592396. PMID 36281094.
  18. ^ Eberhart, L. H. J.; Morin, A. M.; Wulf, H.; Geldner, G. (November 2002). "Patient preferences for immediate postoperative recovery". British Journal of Anaesthesia. 89 (5): 760–761. doi:10.1093/bja/89.5.760. PMID 12393775.

Further reading

[edit]
[edit]
Retrieved from "https://en.wikipedia.org/w/index.php?title=Postoperative_nausea_and_vomiting&oldid=1285427925"