Gan proposed a strategy to identify and manage patients at risk for postoperative nausea and vomiting (PONV). This can help reduce the incidence and severity of disease. The author is from Duke University in Durham, North Carolina.
Strategy:
(1) identify high-risk patients
(2) avoid emetogenic stimuli
(3) treat with antiemetics
(4) treat with other modalities
Risk factors for PONV utilized:
(1) gender
(2) smoking status
(3) previous history of PONV or motion sickness
(4) opioid use
(5) surgical factors
|
Parameter |
Finding |
Points |
|
gender |
male |
0 |
|
|
female |
1 |
|
smoking status |
smoker |
0 |
|
|
nonsmoker |
1 |
|
history of PONV or motion sickness |
absent |
0 |
|
|
present |
1 |
|
opioid use |
no |
0 |
|
|
yes |
1 |
Surgical factors (1point for each factor present):
(1) laparatomy
(2) laparoscopy
(3) plastic surgery
(4) major breast surgery
(5) craniotomy
(6) otolaryngologic surgery
(7) surgery to correct strabismus
where:
• The first 4 risk factors are from he simplified risk score of Apfel et al.
number of risk factors =
= SUM(points for all 5 parameters)
Interpretation:
• minimum number of risk factors: 0
• maximum number of risk factors: 5+
• The higher the number of risk factors, the higher the PONV risk.
|
number of risk factors |
PONV risk |
|
0 |
low |
|
1 |
mild |
|
2 |
moderate |
|
3 |
moderate to high |
|
4 |
high |
|
>= 5 |
extremely high |
|
PONV Risk |
Anti-Emetic Therapy |
|
low |
none |
|
mild |
one of the following: droperidol, dexamethasone, scopolamine, serotonin antagonist |
|
moderate |
one of the following: droperidol, dexamethasone, scopolamine, serotonin antagonist |
|
moderate to high |
(droperidol or dexamethasone) and a serotonin antagonist |
|
high |
(droperidol or dexamethasone) and a serotonin antagonist |
|
extremely high |
combination antiemetics plus total intravenous anesthesia using propofol |
Emetogenic stimuli to avoid:
(1) etomidate
(2) inhalational anesthetic agents
(3) opioids (alternative methods of analgesia if possible, minimum dose if required for pain control)
Other modalities:
(1) total intravenous anesthesia using propofol
(2) keeping the patient well-hydrated
(3) anxiolysis with benzodiazepines
(4) supplemental oxygen (FIO2 >= 0.8)
(5) nonpharmacologic techniques
(6) analgesia with local anesthetics and/or cyclooxygenase 2 inhibitors
Specialty: Anesthesiology, Gastroenterology, Pharmacology, clinical
