The management of post-operative nausea and vomiting

Despite the advent of new technology and pharmacological agents, post-operative nausea and vomiting (PONV) continues to have an incidence of 20-30% today. Development of PONV can lead to serious complications such as aspiration, dehydration, electrolyte disturbances and disruption of the surgical site. PONV leads to increased cost of treatment, and may be associated with increased anxiety, dissatisfaction with the surgical experience and anticipatory nausea in the future. The mechanisms of PONV are examined with associated risk factors. A review of the literature of PONV management is included covering pharmacological, dietary and behavioural interventions; culminating in the development of assessment and management guidelines and identification of areas for further study.     

Meclizine in combination with ondansetron for prevention of postoperative nausea and vomiting in a high-risk population

Postoperative nausea and vomiting (PONV) is prevalent in surgical patients with known risk factors: general anesthesia, female, nonsmoker, motion sickness history, and PONV history. Common treatment involves ondansetron; however, the effects are short-lived, and supplemental medication may be required. Meclizine, a long-acting drug with a low side-effect profile, may be ideal in combination with ondansetron for at-risk patients. We randomized 77 subjects scheduled for general anesthesia and screened for 4 of 5 PONV risk factors for experimental or control group assignment. Severity of PONV was measured using a 0 to 10 verbal numeric rating scale (VNRS). Other measured variables included time to onset and incidence of PONV and total antiemetic requirements. No significant differences in demographics (excluding weight), surgical or anesthesia time, analgesic requirements, or nausea incidence in the postanesthesia care unit (PACU) and same-day surgery unit were noted. The meclizine group had lower VNRS scores in the PACU at 15 (P = .013) and 45 (P = .006) minutes following rescue treatment. The incidence of nausea was lower in the meclizine vs. placebo group (10% vs. 29%) following discharge (P = .038). Prophylactic meclizine resulted in lower incidence and severity of PONV in a high-risk population, especially after rescue treatment.     

Predictors of Postoperative Nausea and Vomiting After Same-day Surgery: A Retrospective Study

PurposePostoperative nausea and vomiting (PONV) are main issues after same-day surgery. This study aimed to retrospectively evaluate the electronic medical records of patients who underwent same-day operations under general anesthesia to identify the potential risk factors for PONV.MethodsRecords of 7759 adult patients who received general anesthesia with remifentanil were reviewed. The patients were assessed for the incidence and severity of PONV. Multiple logistic regression was used to identify risk factors for PONV. A nomogram was established to predict PONV after same-day operations.FindingsOf 7759 patients, 2317 (29.9%) experienced PONV. In multiple logistic regression analysis, female sex, nonsmoker status, history of motion sickness or nausea, high body mass index (BMI), long surgical duration, laparoscopic procedure, and preoperative analgesic intake within 30 days were independent risk factors for PONV. No correlation was found between the severity of PONV and remifentanil exposure (odds ratio = 1.018; 95% CI, 0.861–1.204; P = 0.834) or remifentanil dose (odds ratio = 1.294; 95% CI, 0.760–2.205; P = 0.343). For the nomogram, which involved sex, laparoscopic procedure, BMI, history of nausea or motion sickness, and analgesic intake within 30 days, the receiver operating characteristic analysis revealed that the AUC values in the training and validation cohorts were 0.81 and 0.83, respectively.ImplicationsPredictors for PONV in same-day surgery include female sex, nonsmoker, history of motion sickness or nausea, high BMI, surgical duration >1 hour, laparoscopic procedure, and preoperative analgesic intake within 30 days. A new predictive model is feasible for predicting the incidence of PONV based on the preoperative and intraoperative predictors.     

Náuseas y vómitos postoperatorios en cirugía mayor traumatológica

ObjectivePostoperative nausea and vomiting (PONV) are common complications during the postoperative period, causing important discomfort to the patient and also can increase morbidity. The objective of our article is to predict the prevalence of postoperative nausea and vomiting, the factors that have an influence on its appearance, and to obtain a predictive model based on prognostic factors.MethodA prospective observational study was conducted on 201 patients who underwent major Orthopaedic and Trauma surgery during the year 2008.A questionnaire was designed to collect the required data as established previously by a standardized protocol, in which was requested, patient demographics, intraoperative and postoperative data, as well as details on any antiemetic treatment that was needed in the recovery ward.ResultsA total of 39.8% patients suffered PONV. Of the females, 46.6% suffered PONV, and 75% had previous history of PONV. A higher prevalence was observed in patients who were subjected to more aggressive surgery.There was a concentration of cases between 5 pm and 7 pm, and also at 8 am.The predictive model was obtained from this formula:Y =  ?1,334 + 0,753*S + 1,5602*NVP + 0,769*IQaConclusionsThe prevalence of PONV in this study has been high, as more a third of the studied population suffered from it.The predictive model should help determine the specific risk of each patient of suffering from PONV, thus being able to define a therapeutic strategy during the preoperative period as well as during the postoperative period. Being female, a previous history of PONV, and undergoing an aggressive surgical procedure are risk factors. Patient mobilization and family visits increase the number of PONV episodes.     

Nausea and vomiting in the ambulatory surgical setting

Postoperative nausea and vomiting (PONV) is a significant problem in the ambulatory surgical setting. PONV results in delayed discharge, increased cost, and decreased patient satisfaction. Treating patients at risk for PONV preemptively before surgery can minimize these negative outcomes. Nurses play a key role in preventing PONV by first identifying patients at risk. Administering medication and fluids, providing comfort measures, and assessing the patient throughout the postoperative course are crucial nursing functions in the treatment of PONV. However, successful patient outcomes require a multidisciplinary approach. There have been great advances in the treatment of this common postoperative complication with improved anesthesia techniques and newer antiemetic drugs. Future research is needed to determine optimal combinations and timing of medications. Effective prevention and treatment of PONV improve patient outcomes and provide a more pleasant postoperative experience for the patient.     

The hidden risk of deep vein thrombosis--the need for risk factor assessment: case reviews

Deep vein thrombosis (DVT) is a very serious, potentially fatal, and very preventable medical condition. It is important for all patients admitted to the hospital to be screened for the risk of developing a DVT. This could be easily accomplished by performing a risk factor assessment-screening tool on all patients. It is also important to educate the medical and nursing staff on the fact that all patients are at risk for developing DVT, not just surgical patients who are often believed to be at the highest risk of DVT. The implementation of the risk factor assessment could potentially save lives and reduce the hospital costs of treating and managing the complications of DVT and venous thromboembolic disease. The cases chosen for review in this article will demonstrate many risk factors that often go overlooked in nonsurgical patients. The implementation of a risk factor assessment tool could potentially aid in the recognition and appropriate prophylaxis of those patients who are at extremely high risk for DVT. Without appropriate recognition of the risk for DVT, patients may be placed at risk for DVT and the potentially fatal and/or debilitating complications associated with the development of DVT.     

Use of Apfel Simplified Risk Score to Guide Postoperative Nausea and Vomiting Prophylaxis in Adult Patients Undergoing Same-day Surgery

PurposeThe quality improvement (QI) project implemented a postoperative nausea and vomiting (PONV) risk screening tool and introduced a risk-tailored prophylactic guideline to identify patients at risk for PONV and aimed to minimize PONV adverse events.DesignThis project represents the initial PDSA (Plan-Do-Study-Act) cycle for quality improvement with use of a pre-post design with two independent groups designed to compare PONV rates before and after implementation of an Apfel Simplified Risk Score screening and prophylactic guideline intervention.MethodsThe project implemented the screening of patient PONV risk using the Apfel Simplified Risk Score and a combination antiemetic drug class prophylactic guideline for adult patients undergoing elective same-day surgery procedures. An online education module was provided to anesthesia professionals and was reviewed in-person with the relevant anesthesia professional team prior to surgery. Pre-implementation (N=107) PONV outcomes were collected. Data collected from a retrospective chart review was used to compare pre- and post-implementation PONV rates (N=96) and determine post-implementation anesthesia professional adherence to guideline recommendations.FindingsForty percent of screened patients were identified as having an increased PONV risk with an Apfel Simplified Risk Score of 3 or 4. The PONV rates for the pre-group (19.6%) and post-group (22.9%) did not significantly differ (P=.5567). Anesthesia professional adherence to administration of the recommended number of antiemetic drug classes was 89.6%. A Spearman point-biserial correlation analysis indicated a significant positive relationship between Apfel Simplified Risk Score and PONV onset in the post-group (r_s=0.21, P=.0428).ConclusionsThe Apfel Simplified Risk Score and prophylactic guideline increased identification of patients at risk for PONV but did not affect PONV rate despite a high anesthesia professional adherence to the guideline recommendations.     

肝癌患者术后恶心呕吐发生现况及影响因素研究

目的 探讨肝癌患者术后恶心呕吐的发生情况及影响因素,为临床护理干预提供参考.方法 采用连续抽样的方法,选取2020年10月—2021年4月于上海市某三级甲等医院行肝切除手术的肝癌患者为研究对象,研究者分别于术后2h、6h、24h评估患者术后恶心呕吐发生情况,并系统收集患者的一般资料、疾病资料、手术情况、麻醉情况以及术后...     

Influence of standardized orders on postoperative nausea and vomiting after gynecologic surgery

OBJECTIVE: The risk of postoperative nausea and vomiting (PONV) after gynecologic surgery remains high, despite effective prophylactic medications. Thus, the objectives of this study were to determine whether standardized orders for the prophylaxis and treatment of PONV in gynecologic surgery patients (1) reduce PONV occurrence, (2) reduce total costs, and (3) influence the choice of medications used for PONV prophylaxis and treatment. METHODS: A retrospective design was employed in which a random sample of 200 patients was selected from each of the two 6-month phases before (pre) and after (post) the implementation of standardized orders for PONV prophylaxis and treatment. The primary outcome was the occurrence of any PONV episode. Logistic regression was used to adjust for potential confounding factors. All costs were in 1999 Canadian dollars (Canadian dollar = US$0.673 in 1999). RESULTS: Characteristics were similar except for surgical and anesthesia length between phases. The proportion of patients who received PONV prophylaxis increased from 31% (pre) to 47% (post; p = 0.002). There was a reduction in the risk of a PONV event in the post-phase (odds ratio [OR] 0.67, 95% CI 0.67 to 0.97; p = 0.04). The risk of PONV was significantly reduced with the administration of prophylactic medications (OR 0.46, 95% CI 0.46 to 0.67; p = 0.001). There was a reduction in the mean number of PONV episodes in the post-phase (1.47 events) versus the pre-phase (1.81 events; p = 0.02). A reduction in mean PONV management costs was observed in the post-phase ($8.31, SD +/- 8.50) compared with the pre-phase ($10.23, SD +/- 8.25; p = 0.02). For mean prophylactic costs, these were significantly higher in the postimplementation phase compared with the preimplementation phase ($1.64, SD +/- 3.36 vs. $0.91, SD +/- 2.43; p = 0.013). For mean total PONV costs (prophylaxis plus management costs), there was a nonsignificant reduction in the postimplementation phase compared with the preimplementation phase ($9.95, SD +/- 9.20 vs. $11.15, SD +/- 8.51, respectively; p = 0.18). Univariate sensitivity analyses revealed that the economic results were sensitive to several parameters. CONCLUSIONS: The implementation of preprinted order forms for PONV prophylaxis and treatment appears to be an effective and economically attractive strategy.     

What are the risk factors for nausea and vomiting after neurosurgery? A systematic review

In their practice of post-operative neurosurgical care, nurses frequently encounter the problem of post-operative nausea and vomiting (PONV). Knowledge of risk factors for PONV can help nurses to identify groups of patients who may encounter PONV and develop related therapeutic guidelines. The purpose of this systematic review was to identify and summarize risk factor research for PONV after neurosurgical procedures. Of 272 papers identified through a systematic search, 13 studies met the criteria for this review. These studies varied considerably in their outcome measurements, risk factors studied, and target populations. The timeframe of observation (for prospective studies) or chart review (for retrospective studies) ranged from one hour after surgery to the entire length of the hospital stay. For these reasons, it was difficult to compare results among the studies. Overall, the methodological quality of the studies was fair, with few studies controlling for confounders and many with limited explanations of how the risk factors and/or outcomes were measured. Despite these limitations, many authors looked at unique risk factors for neurosurgical patients such as location of surgery (i.e., infratentorial versus supratentorial), awake versus general anesthesia, and use of fat grafting for cerebral spinal fluid leak in transsphenoidal procedures. The findings may challenge traditional thinking about risk factors for PONV and guide future studies.     

Preoperative assessment of cardiac patients undergoing noncardiac surgical procedures

A careful clinical history and physical examination are the most important components of the preoperative assessment of the cardiac patient who is to undergo a noncardiac surgical procedure. From these factors and the nature of the surgical procedure planned, a reasonable estimate of potential cardiac risk can be formulated to guide judicious preoperative testing for further definition of potentially high-risk patients. The potential risks associated with an invasive cardiac procedure or surgical intervention must always be considered along with the potential benefits of such a procedure in an attempt to reduce the cardiac risk of noncardiac operations. Aggressive and conscientious preoperative assessment and perioperative care of the high-risk patient by the concerted efforts of the medical consultant, anesthesiologist, and surgeon may substantially diminish cardiac-related morbidity and mortality during noncardiac surgical procedures.     

Postdischarge Nausea and Vomiting Risk Assessment in Breast and Gynecologic Surgical Patients

PurposePostdischarge nausea, vomiting, and retching often occur after the time of discharge from the postanesthesia care unit (PACU) in patients who have undergone outpatient surgeries. At a large mid-Atlantic Academic Hospital, 40% of gynecologic outpatient surgical patients had postdischarge nausea and vomiting (PDNV). The purpose of this quality improvement project was to implement and evaluate the effectiveness of and staff compliance with the Apfel Postdischarge Nausea and Vomiting Risk Assessment tool to improve PDNV risk screening in the PACU.DesignThis quality improvement project was part of an evidence-based practice project.MethodsAfter identification and recruitment of key stakeholders and unit champions, a force-field analysis, as part of Lewin's change theory, was completed to identify the driving and restraining forces. All PACU registered nurses received education on the risk assessment protocol using the Apfel risk assessment tool. The Apfel risk assessment tool has been validated to identify five independent risk factors for PDNV in outpatient ambulatory surgical populations. Implementation of the tool with data collection occurred for 8 weeks on all scheduled outpatient breast and gynecologic surgical patients. Staff compliance was measured throughout implementation.FindingsIn patients with at least three risk factors present, the Apfel tool correctly identified the risk for PDNV in 68% of patients. In patients with four and five risk factors present, the tool correctly identified the risk for PDNV in 88% and 100% of patients, respectively. Compliance with the tool was high with an average compliance rate of 92% for the 8-week data collection period.ConclusionsData analysis demonstrated that the Apfel risk assessment tool adequately predicted the risk for PDNV in outpatient surgical breast and gynecologic patients. Use of Lewin's change theory was successful in maintaining a high compliance rate throughout implementation. In addition, this quality improvement project resulted in increased compliance of the standing follow-up phone call policy. Efforts toward sustainment include expansion to all outpatient surgical populations and implementation of a PDNV prevention and management guideline.     

Efficacy of prophylactic ondansetron in a patient-controlled analgesia environment

We conducted a prospective, randomized, double-blind, placebo-controlled trial to examine the efficacy of prophylactic ondansetron on post-operative nausea and vomiting (PONV) during opioid patient-controlled analgesia (PCA). In total, 374 patients using opioid PCA, but otherwise considered to be low risk for PONV, were randomly allocated to ondansetron (4 mg given intravenously and 16 mg added into the PCA pump) or saline (control group). PONV was evaluated in terms of nausea graded on a visual analogue scale, and the number of patients who experienced emetic episodes or needed rescue anti-emetics in the 48-h post-operative period. Patient satisfaction for PCA was scored at the end of the evaluation period. The only difference between the two groups was the higher number of headaches in the ondansetron group. In patients using opioid PCA, but with no other high risk factors for PONV, prophylactic ondansetron does not have any clinical benefit.     

术后恶心和呕吐非药物管理的最佳证据总结

目的 总结术后恶心和呕吐非药物管理的最佳证据,为术后恶心和呕吐患者的临床护理实践提供参考。方法 根据循证护理的方法明确问题,并根据“6S”证据模型,检索有关术后恶心和呕吐的国内外证据,包括指南、共识、临床决策、证据总结类文献,由2名完成循证护理培训的研究员对纳入的文献独立评价,并对符合标准的文献进行证据提取。结果 共纳入证据15篇,包括临床决策1篇,指南4篇,系统评价5篇,证据总结3篇,最佳实践1篇,专家共识1篇。汇总出术后恶心和呕吐非药物管理的最佳证据9个方面共26条。结论 临床管理者需加强对术后恶心和呕吐的风险评估、非药物管理方法进行规范化培训。非药物方法可以从穴位刺激、耳穴压豆、呼吸控制指导、咀嚼口香糖这些方面进行选择形成适合科室的措施,应用于术后恶心和呕吐患者的科学管理。     

Standardizing Documentation for Postoperative Nausea and Vomiting in the Electronic Health Record

Postoperative nausea and vomiting (PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Clinicians use the American Society of PeriAnesthesia Nurses (ASPAN) guideline to help prevent and treat PONV. However, the lack of standardized terminology in the electronic health record (EHR) and the lack of clinical decision support tools make it difficult for clinicians to document guideline implementation and to determine the effects of nursing care on PONV. To address this, we created a concept map of the Perioperative Nursing Data Set (PNDS) that illustrates the relationship between elements of this standardized nursing terminology and the ASPAN guideline, using the Systematized Nomenclature of Medicine—Clinical Terms multidisciplinary terminology to fill any gaps. This mapping results in a standardized dataset specific to PONV for use in an EHR, which links nursing care to nursing diagnoses, interventions, and outcomes. The mapping and documentation in the EHR also allows standardized data collection for research, evaluation, and benchmarking, which makes perioperative nursing care of patients who are at risk for or experiencing PONV measureable and visible. Distributing this information to perioperative and perianesthesia nursing personnel, in addition to implementing risk assessment tools for PONV and clinical support alerts in electronic documentation systems, will help support implementation of the PONV clinical practice guideline in the EHR.     

两种术后恶心呕吐风险评分在老年患者胸腔镜部分肺切除中的应用及比较

目的 探讨并比较2种术后恶心呕吐（postoperative nausea and vomiting，PONV） 风险评分在老年患者胸腔镜肺切除中的预测效果。方法 采用便利抽样法，收集2021年10月-2022年1月南京医科大学附属脑科医院（胸科院区）胸外科行肺切除的老年患者为研究对象，根据是否发生PONV将患者分为PONV组（n=74）和非PONV组（n=153）。分别应用Apfel和Koivuranta风险评分预测每例患者PONV发生风险，采用受试者工作特征曲线下面积(AUROC)评价2种评分的区分能力；采用 Hosmer-Lemeshow拟合优度检验评价2种评分的校准度。结果 227例患者中，发生PONV 74（32.6%）例，2种评分在老年患者胸腔镜肺切除PONV风险预测中的AUROC 值分别为0.640和0.683，两者比较差异无统计学意义（Z=1.535，P=0.125），Hosmer-Lemeshow 拟合优度检验结果显示，2种评分的校准度较好（P＞0.05）。结论 2种风险评分在老年患者胸腔镜肺切除PONV风险预测中的区分度一般，AUROC值均低于原始模型。Koivuranta评分更适用于老年患者胸腔镜肺切除PONV风险预测，但适用性不足。     

Influence of postoperative pain therapy on nausea and vomiting

PROBLEM: Postoperative nausea and vomiting remains an important problem. Many risk factors have been identified; however, the importance of postoperative analgesic technique and patient expectation remain poorly defined. METHODS: We prospectively collected data on postoperative nausea and vomiting (PONV) in four groups of randomly selected patients (n=50 per group) who received either simple analgesics, nurse-administered intravenous morphine (NAA), patient-controlled analgesia (PCA) with morphine or epidural analgesia with bupivacaine and fentanyl. Patients were questioned regarding any past history of PONV or motion sickness, their preoperative expectation of suffering PONV and satisfaction with their antiemetic therapy. RESULTS: The incidence of nausea was higher in both morphine groups P<0.05), women (P<0.05), those less than the median age of their group (P<0.05) and those with a past history of PONV (P<0.05) or motion sickness (P<0.05). Most patients did not expect to experience PONV (19.3%). The incidence of nausea was higher in those expecting to experience PONV than in those not expecting to suffer PONV (P<0.01). Of those who received postoperative antiemetic treatment, 23.6% were dissatisfied or very dissatisfied with their therapy. Few patients received a prophylactic antiemetic drug (15%). CONCLUSIONS: Study results show that patient expectation is a potent predictor of postoperative nausea, a risk factor hitherto ignored in the anaesthetic literature, and that, in the provision of analgesia following major surgery, epidural analgesia is associated with less PONV than intravenous morphine.     

Prevention and Management of Postoperative Nausea and Vomiting in Adults

In early 2007, patients at our small community hospital's outpatient surgery center experienced postoperative nausea and postoperative nausea and vomiting (PONV) at a rate of 27% to 35%. Many record reviews and a written survey of nurses in the postanesthesia care unit and same day surgery center revealed that little or no risk assessment and no consistent prophylaxis or treatment were in use by nurses, physicians, or anesthesia care providers.After a review of the literature and discussions with anesthesia care providers, we developed and put into practice a risk assessment tool and perioperative care path. A formal evaluation to assess the effectiveness of the plan was performed one year after implementation. We found that the rates of PONV had decreased to 16%. AORN J 90 (September 2009) 391-413. © AORN, Inc, 2009.     

Renewal of surgical quality and safety initiatives: a multispecialty challenge

The quality and safety movement in surgical specialty practice is gaining momentum. On the basis of risk-adjusted outcomes of coronary artery surgery and the improved risk assessment in the Veterans Affairs system, a growing array of surgical specialists has focused on recognition of legitimate risk factors, identification of performance measures that are valid surrogates for better practices, and refinement of risk-adjusted outcomes. Recognition of educational needs, personal practice patterns, and systems deficiencies now permits a broad-based application of long-standing primarily medical issues to elective surgical procedures in an organized and Integrated fashion. Approximately 85,000 patients per day undergo elective operations in the United States. A platform based on physician involvement and leadership has been tested in the Surgical Care Improvement Project, funded by a subcontract from the Centers for Medicare and Medicaid Services. This effort has defined factors worthy of further verification and provides a framework for an ethical and valid pay-for-performance scheme.