Ponv anaesthesia managment


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  • A study conducted at Stanford University Medical Center was designed to quantify patients’ preferences regarding common, low-morbidity anesthesia postoperative outcomes, such as incisional pain, nausea, or shivering. The survey instrument developed by researchers allowed patients to rank possible outcomes from 1 to 10 (1=most undesirable and 10=most desirable). One hundred one adult patients (aged ≥18 years) who were scheduled to undergo surgery in either the outpatient surgery center or main tertiary hospital surgery suite completed and returned the survey instrument to the preoperative evaluation anesthesia clinic. 1 As shown in this table, patients ranked vomiting as the least preferred outcome ( F -test <0.01), viewing postoperative vomiting as even less preferred than pain. Nausea also ranked among the 5 least preferred postoperative anesthesia outcomes. 1 In order from the least preferred to the most preferred, the other outcomes were ranked: 5) recall without pain (ie, patient remembers being awake during surgery, unable to move or talk); 6) residual weakness; 7) shivering; 8) sore throat; and 9) somnolence. 1 These results are consistent with other research involving patient preferences for symptoms during the immediate postoperative recovery period. A study involving 200 women who underwent elective gynecologic surgery showed that the relative importance to patients of not experiencing symptoms of PONV, pain, and sedation was 74%, 23%, and 3%, respectively. 2 References: 1. Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg . 1999;89:652–658. 2. Lee A, Gin T, Lau ASC, Ng FF. A comparison of patients’ and health care professionals’ preferences for symptoms during immediate postoperative recovery and the management of postoperative nausea and vomiting. Anesth Analg . 2005;100:87–93.
  • This slide depicts key neurotransmitters involved with emesis. The brainstem vomiting center contains high concentrations of several neurotransmitter receptors, including receptors for acetylcholine, histamine, dopamine, opioid, and serotonin. 1 This anatomic region is also rich in neurokinin 1 (NK 1 ) receptors, which have a high affinity for the recently identified emetic neurotransmitter, substance P. 2,3 By serving as sensors that can be stimulated by drugs, electrolytes, and metabolic chemicals, these receptors relay impulses to the vomiting center and initiate the vomiting reflex. 4 Blockade, or antagonism, of these receptor sites is the mechanism of action of many of the pharmacologic antiemetic agents commonly used for PONV. 1,4 Many currently available antiemetic medications for use in PONV were first developed to treat motion sickness as well as nausea and vomiting induced by chemotherapy and radiation therapy. 4 However, because afferent systems trigger the release of various neurotransmitters, an antiemetic that is effective against one type of vomiting can be ineffective against emesis induced by other stimuli. For example, serotonin 5-HT 3 receptor antagonists exhibit potent antiemetic activity against acute chemotherapy-induced nausea and vomiting but do not inhibit response to other emetogens, such as motion or opioid and dopaminergic agonists. 5 Some receptors, such as 5-HT 3 and NK 1 , are found both peripherally and in the CNS. 3,6 Whereas 5-HT 3 receptor antagonists exert their antiemetic activity primarily on abdominal vagal afferents, it appears that the substance P/NK 1 emetic pathway is primarily centrally mediated. 6 References: 1. Nelson TP. Postoperative nausea and vomiting: understanding the enigma. J Perianesth Nurs . 2002;17:178–189. 2. Cameron D, Gan TJ. Management of postoperative nausea and vomiting in ambulatory surgery. Anesthesiol Clin North America . 2003;21:347–365. 3. Harrison S, Geppetti P. Substance P. Int J Biochem Cell Biol . 2001;33:555–576. 4. Kovac AL. Prevention and treatment of postoperative nausea and vomiting. Drugs . 2000;59:213–243. 5. Diemunsch P, Grélot L. Potential of substance P antagonists as antiemetics. Drugs . 2000;60:533–546. 6. Saito R, Takano Y, Kamiya H. Roles of substance P and NK 1 receptor in the brainstem in the development of emesis. J Pharmacol Sci . 2003;91:87–94. Nelson p. 180/A; p. 182/A Cameron p. 348/A; p. 349/A Nelson p. 180/A; p. 182/A Kovac p. 220/A Cameron p. 348/A; p. 349/A Harrison p. 558/A; p. 559/A Diemunsch p. 534/A; p. 535/A Harrison p. 556/B Saito p. 91/A Kovac p. 216/A,B Nelson p. 182/A Apfel 1999 p. 693/B Cameron p. 348/A; p. 352/A Kovac p. 220/B Harrison p. 558/A; p. 559/A Nelson p. 180/A; p. 182/A Kovac p. 216/A
  • A simplified risk model developed by Apfel and colleagues was validated in 2 medical centers, involving a total of 2,722 adult patients. All patients received inhalational anesthesia, without antiemetic prophylaxis, for various types of surgery. If needed, nonsteroidal analgesic drugs or opioids (eg, oxycodone or tramadol) were used to treat postoperative pain. Statistical analyses identified 4 predictors of PONV: history of PONV or motion sickness, female sex, nonsmoking, and the use of postoperative opioids. 1 In addition, researchers correlated the incidence of PONV with the number of risk factors present. The risk of PONV increased with the presence of each additional primary risk factor, representing a 30% to 110% relative increase with each additional risk factor 1 : 0 risk factors present : Associated with 10% incidence of PONV 1 risk factor present : Associated with 21% incidence of PONV 2 risk factors present : Associated with 39% incidence of PONV 3 risk factors present : Associated with 61% incidence of PONV 4 risk factors present : Associated with 79% incidence of PONV Based on this approach to risk modeling, a prophylactic antiemetic strategy is recommended for patients with 2 or more of these identified risk factors. 1 Reference: 1. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting. Anesthesiology . 1999;91:693–700.
  • For more than 50 years, scientists have studied different classes of agents and their effectiveness in preventing PONV. Phenothiazines and antihistamines were developed in the 1950s. Butyropherones, substituted benzamides, and anticholinergics were introduced in the 1970s. In 1991, there was a significant breakthrough in emetic prevention with the development of 5-HT 3 receptor antagonists. These agents introduced substantial protection from PONV that previous classes did not offer. However, as shown previously, PONV remains a problem in up to 30% of all surgeries and patient populations despite current therapies. 1–3 Therefore, it was important to further the treatment paradigm to augment prevention of PONV. In 2006, more than 10 years after 5-HT 3 receptor antagonists were approved, the FDA approved EMEND ® (aprepitant)—the first and only substance P/NK 1 receptor antagonist for prevention of PONV. References: 1. Kovac AL. Prevention and treatment of postoperative nausea and vomiting. Drugs . 2000;59:213–243. 2. Habib AS, Gan TJ. Evidence-based management of postoperative nausea and vomiting: a review. Can J Anesth . 2004;51:326–341. 3. Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med . 2004;350:2441–2451.
  • As a selective substance P/NK 1 receptor antagonist, EMEND ® (aprepitant) has a high affinity for NK 1 receptors located throughout the body. 2,3 In the illustration on this slide, the large multicolored structure represents the NK 1 receptor site. EMEND (the yellow chemical structure) is seen preventing substance P from binding to the site. The NK 1 receptor is a member of the pGPCR (peptidergic G-protein coupled receptor) family of receptors. Its principal signal transduction mechanism is Gq/11. This protein is linked to activation of phospholipase, which mediates an increase in intracellular calcium. 1 The NK 1 receptor is sometimes referred to as the substance P receptor because substance P is its preferred ligand. EMEND is a selective substance P/NK 1 receptor antagonist with a high affinity for NK 1 receptors located throughout the body. 2,3 Substance P can be thought of as a neuromodulator that amplifies the effects of other transmitters acting on the same cells. Therefore, blockade of substance P can have both direct and indirect effects on signaling because the actions of other transmitters are not amplified or exaggerated. As an NK 1 receptor antagonist, EMEND prevents the binding of substance P to the NK 1 receptor, preventing the activation of the signal transduction pathways and subsequent effects on cell physiology and signaling. References: 1. Alexander SPH, Mathie A, Peters JA. Guide to receptors and channels, 2nd edition. Br J Pharmacol . 2006;147(suppl 3):S1–S180. 2. Keller M, Montgomery S, Ball W, et al. Lack of efficacy of the substance P (neurokinin 1 receptor) antagonist aprepitant in the treatment of major depressive disorder. Biol Psychiatry . 2006;59:216–223. 3. Hargreaves R. Imaging of substance P receptors (NK 1 ) in the living human brain using positron emission tomography. J Clin Psychiatry . 2002;63(suppl 11):18–24.
  • Ponv anaesthesia managment

    1. 1. Postoperative Nausea and Vomiting
    2. 3. Definitions <ul><li>Vomiting :Forceful oral expulsion of gastric contents associated with contraction of abdominal and chest wall musculature. </li></ul><ul><li>Nausea: The unpleasant sensation of imminent need to vomit, usually referred to throat or epigastrium; a sensation that may or may not ultimately lead to the act of vomiting. </li></ul>
    3. 4. The Facts <ul><li>Vomiting - unpleasant and medical risks : aspiration of gastric content; jeopardizes abdominal or inguinal closures; increased IV pressure: increase morbidity after ocular , tympanic , intracranial procedures ; elevate HR and BP: risk for MI and dysrhythmias ; gagging and retching: parasympathetic response: bradycardia and hypotension . </li></ul><ul><li>PONV increases </li></ul><ul><ul><ul><li>Time spent in recovery </li></ul></ul></ul><ul><ul><ul><li>Need for nurses </li></ul></ul></ul><ul><ul><ul><li>Need to admit overnight </li></ul></ul></ul><ul><li>This all leads to increased healthcare costs. </li></ul><ul><li>More than 25% of patients report experiencing PONV, with numbers reaching as high as 80% in high risk populations. </li></ul>
    4. 5. PONV: A Problem Adapted from Macario A et al. Anesth Analg . 1999;89:652–658. © 1999. With permission from Lippincott Williams & Wilkins. Data from a survey of adult patients (N=101) conducted at Stanford University Medical Center. Patients were eligible if they were scheduled to undergo surgery at the center. Patients were asked to rank-order 10 possible postoperative outcomes from most to least desirable. F -test <0.01. Emesis is the postoperative outcome least preferred by patients Recall without pain 5 Residual weakness 6 Shivering 7 Sore throat 8 Somnolence 9 Incisional pain 3 Gagging on endotracheal tube 2 Nausea 4 Vomiting 1 Postoperative Outcomes Rank Postoperative Outcomes Least Preferred by Patients
    5. 6. Physiology of Nausea and Vomiting
    6. 7. Initiation of the Cascade <ul><li>Complex interaction of receptors, chemicals, and organ systems </li></ul><ul><li>Mediated though the vomiting center located in the dorsal area of the reticular formation of the medulla </li></ul>
    7. 8. Vomiting Center <ul><li>Composed of three nuclei </li></ul><ul><ul><li>The nucleus tractus solitarius (receives sensory information from several afferent pathways) </li></ul></ul><ul><ul><li>The dorsal motor nucleus of the vagus </li></ul></ul><ul><ul><li>The nucleus ambiguus (primarily involved with the coordination of motor activity during the act of vomiting) </li></ul></ul><ul><li>5 primary afferent pathways </li></ul><ul><ul><li>Chemoreceptor triggering zone </li></ul></ul><ul><ul><li>Vagal mucosal pathway in GI system </li></ul></ul><ul><ul><li>Neuronal pathways from the vestibular system </li></ul></ul><ul><ul><li>Reflex afferent pathways from the cerebral cortex </li></ul></ul><ul><ul><li>Midbrain afferents </li></ul></ul>
    8. 9. Key Neurotransmitters in the Brainstem Vomiting Center <ul><li>Opioid receptors are also located in the chemoreceptor trigger zone (CTZ); opioids are a risk factor for PONV. 1,5 </li></ul>Emetic Reflex Center 1–4 1. Nelson TP. J Perianesth Nurs . 2002;17:178–189. 4. Kovac AL. Drugs . 2000;59:213–243. 2. Cameron D, Gan TJ. Anesthesiol Clin North America . 2003;21:347–365. 5. Apfel CC et al. Anesthesiology . 1999;91:693–700. 3. Harrison S, Geppetti P. Int J Biochem Cell Biol . 2001;33:555–576. Substance P- NK 1 Receptor Serotonin- 5-HT 3 Receptor Acetylcholine- Muscarinic Receptor Cholinergic Receptor Dopamine- D 2 Receptor Histamine- H 1 Receptor
    9. 10. Cascading information <ul><li>Information is transmitted to the vomiting center from several different areas through chemical stimulation of a variety of receptors </li></ul>
    10. 11. First Signal <ul><li>Originates in CNS </li></ul><ul><li>Neurotransmitters responsible </li></ul><ul><ul><li>Acetylcholine </li></ul></ul><ul><ul><li>Histamine </li></ul></ul><ul><li>How to block transmission </li></ul><ul><ul><li>Anticholinergic agents that block binding of acetylcholine (scopolamine) </li></ul></ul><ul><ul><li>Diphendyramine (blocks the action of histamine) </li></ul></ul><ul><ul><li>Older drugs (promethazine and haloperidol) exact mechanism poorly understood </li></ul></ul>
    11. 12. Increasing Sensitivity <ul><li>Anesthetic agents and administered opioids increase the sensitivity of the vestibular center </li></ul><ul><li>Rapid position change or movement of a sensitive patient may lead to the development of PONV </li></ul><ul><li>Position changes should be made slowly and patients should be instructed to keep their eyes closed during transport </li></ul>
    12. 13. 2 nd Signal <ul><li>Gastrointestinal tract via vagus nerve </li></ul><ul><li>GI distention and manipulation leads to stimulation of mechanoreceptors in the wall of the gut and the release of serotonin </li></ul><ul><li>The administration of a selective serotonin antagonist at the 5-hydroxtryptamine 3 decreases the visceral information carried from the GI tract to the vomiting center </li></ul>
    13. 14. 3 rd Signal <ul><li>Chemoreceptor trigger zone located on the floor of the fourth ventricle in the brain </li></ul><ul><li>Close association with cerebrospinal fluid </li></ul><ul><li>Large blood supply not protected by the blood brain barrier </li></ul><ul><li>Detects the presence of drugs or toxins </li></ul><ul><li>Culprit for severe nausea and vomiting associated with the administration of antineoplastic agents </li></ul>
    14. 15. CTZ Zone
    15. 16. Mechanisms of CTZ <ul><li>Works through the 5-HT 3 receptors as well as dopamine type 2 receptors </li></ul><ul><li>D2 antagonists (prochloroperazine, droperidol, and metoclopramide) </li></ul><ul><li>5-HT 3 antagonists (dolasetron, ondansetron, and granisetron) </li></ul>
    16. 17. Slowing down the Heart Rate…. <ul><li>With vomiting, the predominate branch of the autonomic nervous system becomes the parasympathetic nervous system </li></ul><ul><ul><li>Hypotension and bradycardia may accompany retching </li></ul></ul>
    17. 18. Risk factors for post-operative nausea and vomiting in adults.
    18. 19. Patient-specific risk factors <ul><li>The most important being: </li></ul><ul><li>Female gender (RCT) </li></ul><ul><li>Non-smoking status (RCT) </li></ul><ul><li>History of PONV/motion sickness (RCT) </li></ul><ul><li>Less important being </li></ul><ul><li>- Age (adult) </li></ul><ul><li>- Predisposing gastric disorders </li></ul><ul><li>- Low threshold for nausea </li></ul><ul><li>- Preoperative anxiety </li></ul><ul><li>- Obesity (disputed in recent studies) </li></ul><ul><li>- Gastric distension (disputed in recent studies) </li></ul>
    19. 20. Anaesthetic risk factors <ul><li>The most important being: </li></ul><ul><li>Use of volatile anaesthetics (RCT) </li></ul><ul><li>Nitrous oxide systematic review (SR) </li></ul><ul><li>Use of intra-operative (SR) and postoperative opioids (RCT) </li></ul><ul><li>Intubation. </li></ul>
    20. 21. Surgical risk factors <ul><li>Duration of surgery (each 30-min increase in duration </li></ul><ul><li>increases PONV risk by 60%, so that a baseline risk </li></ul><ul><li>of 10% is increased by 16% after 30 min) (Prospective observational study) </li></ul><ul><li>Type of surgery (laparoscopy, laparotomy, breast, </li></ul><ul><li>strabismus, plastic surgery, maxillofacial, gynecological, abdominal, neurologic, ophthalmologic, urologic) (Prospective observational study) </li></ul><ul><li>Early oral intake </li></ul>
    21. 22. 4 important risk factors <ul><ul><li>Female gender </li></ul></ul><ul><ul><li>Nonsmoking status </li></ul></ul><ul><ul><li>History of PONV or motion sickness </li></ul></ul><ul><ul><li>Use of postoperative opioids for the peri-operative care of surgical pain </li></ul></ul>
    22. 23. Impact of Multiple Patient-Related Risk Factors* Risk of PONV Increased Based on Number of Primary Risk Factors Present * Validated in 2,722 adult patients receiving inhalational anesthesia. Apfel CC et al. Anesthesiology . 1999;91:693–700. Primary Risk Factors: History of PONV or motion sickness ■ Female sex ■ Nonsmoking ■ Use of postoperative opioids Patients With PONV, %
    23. 24. Options available
    24. 26. Evolution of Antiemetics for PONV 5-HT 3 =serotonin receptor type 3. 1950s 1960s 1970s 1980s 1990s 2000s Phenothiazines Antihistamines Butyropherones Substituted benzamides Anticholinergics 5-HT 3 receptor antagonists Substance P/NK 1 receptor antagonists
    25. 27. Droperidol (Inaspine) <ul><li>Butyrophenone </li></ul><ul><li>Blocks dopamine-2 receptors in the CTZ and area postrema </li></ul><ul><li>Usual adult dose: 0.625-1.25 mg IV </li></ul><ul><li>Duration of action: up to 12-24 hours </li></ul><ul><li>Adverse effects: sedation, dizziness, anxiety, hypotension, extrapyramidal side effects </li></ul><ul><li>More effective for nausea than vomiting </li></ul><ul><li>FDA BLACK BOX WARNING 2001 </li></ul><ul><ul><li>Increased risk of lengthening of the QT intervals in some patients </li></ul></ul><ul><ul><li>Risk for cardiac patients!!! </li></ul></ul>
    26. 28. Metoclopramide (Reglan) <ul><li>Benzamide </li></ul><ul><li>Blocks dopamine-2 receptors in the CTZ and vomiting center </li></ul><ul><li>Prokinetic properties that quicken esophageal clearance, enhance gastric emptying, and shorten bowel-transit time </li></ul><ul><li>Less effective than ondansetron or droperidol </li></ul><ul><li>Most commonly administered dose of 10 mg IV is not effective for prevention of PONV </li></ul>
    27. 29. Metoclompramide (Reglan) <ul><li>Usual adult dose for PONV: 25-50 mg IV </li></ul><ul><ul><li>10-20 mg IV for rescue N/V </li></ul></ul><ul><li>Duration of action: up to 6 hours </li></ul><ul><li>Adverse effects: sedation, hypotension, extrapyramidal symptoms, restlessness </li></ul>
    28. 30. Promethazine (Phenergan) <ul><li>Phenothiazine </li></ul><ul><li>Blocks dopamine-2 receptors in the CTZ and other areas of the brain </li></ul><ul><li>Also blcoks histamine-1 receptors and msucarinic-1 receptors </li></ul><ul><li>Usual adult dose: 6.25-12.5 mg IV </li></ul><ul><li>Duration of action: 4-6 hours </li></ul><ul><li>Adverse effects: sedation, hypotension, extrapyramidal symptoms </li></ul>
    29. 31. Diphenhydramine (Benadryl) <ul><li>Antihistamine </li></ul><ul><li>Suppresses motor-enhanced vestibular neuronal firing </li></ul><ul><li>Adverse reactions: sedation, dry mouth, blurred vision, urinary retention </li></ul>
    30. 32. Scopolamine <ul><li>Anticholinegic </li></ul><ul><li>Transdermal patch </li></ul><ul><li>Blocks the muscarinic-1 receptors in the cerebral cortex and pons and histamine-1 receptors in the hypothalamus and vomiting center to exert its antiemetic effects </li></ul><ul><li>Suppresses the noradrenergic system (improved adaptation to vestibular stimulation) </li></ul><ul><li>4 hour onset of action </li></ul><ul><ul><li>Needs to be placed the night before for patients with increased risk of PONV </li></ul></ul>
    31. 33. Dexamethasone <ul><li>Corticosteroid </li></ul><ul><li>Antiemetic action not fully understood </li></ul><ul><li>Thought to work by </li></ul><ul><li>inhibition of prostaglandin syn. </li></ul><ul><ul><ul><li> tryptophan </li></ul></ul></ul><ul><ul><ul><li>release of endorphins </li></ul></ul></ul><ul><ul><ul><li>change in CSF opening pressure </li></ul></ul></ul><ul><ul><ul><li>+ psychological effects of steroids </li></ul></ul></ul><ul><li>ACUTE SIDE EFFECTS : flushing and perineal itching. </li></ul>
    32. 34. NK1 Receptor Antagonist: Aprepitant <ul><li>Newest class of antiemetics </li></ul><ul><li>Antagonists at the neurokinin type-1 receptors </li></ul><ul><ul><li>Substance P is a neurokinin neurotransmitter that acts through neurokinin type-1 receptors found in the central and peripheral nervous system to induce nausea and vomiting </li></ul></ul><ul><li>FDA approved when used with standard antiemetics to prevent PONV in patients undergoing highly ematogenic chemotherapy </li></ul>
    33. 35. EMEND ® (aprepitant) Blocks Substance P From Binding to NK 1 Receptors EMEND Substance P NK 1 receptor 1. Keller M et al. Biol Psychiatry . 2006;59:216–223. 2. Hargreaves R. J Clin Psychiatry . 2002;63(suppl 11):18–24. Binding of EMEND at the NK 1 Receptor Site 1,2
    34. 36. Supplemental Oxygen <ul><li>Attenuates the release of serotonin from the vagal afferent nerves in the GI tract by increasing oxygen concentration to the tissues, thus enhancing delivery of oxygen to the intestine </li></ul><ul><li>GI tract has high metabolic demands and is intolerant to hypoxia or ischemia </li></ul>
    35. 37. Link between Laparoscopy and Oxygen <ul><li>Patients undergoing laparoscopy have reduced intestinal blood flow as a result of insufflation of the abdomen </li></ul>
    36. 38. Complementary Therapies: Acupuncture and Related Techniques <ul><li>Traditional Chinese medicine treated nausea and vomiting with acupuncture </li></ul><ul><li>Uses needles that are inserted into traditional acupuncture points in the body, initiating a series of physiological events that counter PONV </li></ul><ul><li>Certain nerve fibers are stimulated that result in nerve impulses being sent to the spinal cord </li></ul><ul><ul><li>Endorphogenic cells are stimulated to release endorphins </li></ul></ul>
    37. 39. Complementary Therapies: Acupuncture and Related Techniques <ul><li>Nerve impulses produced by acupuncture also transmit to the periaqueductal gray area of the midbrain where enkephalin is released </li></ul><ul><ul><li>Causes a release of the monoamine neurotransmitters serotonin and norepinephrine in the spinal cord </li></ul></ul><ul><li>3 rd effect is release of beta-endorphins and adrenocorticotropic hormone (ACTH) from the pituitary gland into the bloodstream and cerebrospinal fluid </li></ul><ul><li>Calming of the GI tract </li></ul>
    38. 40. Complementary Therapies: Acupuncture and Related Techniques <ul><li>Acupressure </li></ul><ul><ul><li>Uses physical and mechanical pressure instead of needles over the same meridians of the body </li></ul></ul>
    39. 41. Complementary Therapies: Aromatherapy <ul><li>Dates back as far as 2800 BC </li></ul><ul><li>Herbal preparations and plant extracts </li></ul><ul><li>Use of oil of ginger as a prophylactic therapy </li></ul><ul><li>Isopropyl alcohol </li></ul><ul><li>Oil of peppermint </li></ul>
    40. 42. Complementary Therapies: Peppermint <ul><li>Remedy for morning sickness, dyspepsia, and other GI complaints </li></ul>
    41. 43. Inhalation of Isopropyl Alcohol Vapors <ul><li>Study of 100 healthy women undergoing outpatient gynecologic laparoscopic procedures </li></ul><ul><li>Randomly received 4 mg ondansetron or 70% isopropyl alcohol for postoperative nausea </li></ul><ul><li>Use of alcohol pads resulting in quicker relief of nausea </li></ul>
    42. 44. Complementary Therapies: Oral Ginger <ul><li>Oral ginger has been used in China for treating GI symptoms such as nausea and vomiting </li></ul><ul><li>Ginger root, ginger powder, ginger candy, and ginger gum </li></ul><ul><li>Ginger oil in form of aromatherapy </li></ul><ul><li>Role not clearly defined by research </li></ul>
    43. 45. Management of the problem
    44. 50. PONV Treatment Pathway - Mass. General Protocol for PONV <ul><li>Step 1. </li></ul><ul><li>Ondansetron 4 mg IV and dexamethasone 4 mg IV as a single dose If nausea and vomiting continues to be problematic after 30 minutes, proceed to step 2: </li></ul><ul><li>Step 2. </li></ul><ul><li>Haloperidol 0.25mg IV or </li></ul><ul><li>Metoclopramide 20 mg IV. May be repeated x1 in 4 hours </li></ul><ul><li>If nausea and vomiting continues to be problematic after 30 minutes, proceed to step 3: </li></ul><ul><li>Step 3. </li></ul><ul><li>Promethazine 12.5 -25 mg IV q 4 h. or Meclizine 25mg orally q 8 h. or Prochlorperazine suppository 25 mg per rectum q 12 h. </li></ul><ul><li>If nausea and vomiting continues to be problematic, proceed to step 4: </li></ul><ul><li>Step 4. </li></ul><ul><li>Droperidol Prior to prescribing droperidol, physician must determine that pre-administration EKG QTc interval is < 440 msec [males] or <450 msec [females]. If within guidelines, then *Give droperidol 1.25 mg IV x 1 dose only *Patient's EKG must be monitored for 2-3 hr post-dose. </li></ul><ul><li>Note: These guidelines were developed by an interdisciplinary group of clinicians from the BWH and MGH Pharmacy and Anesthesia Departments. </li></ul><ul><li>http://www.massgeneral.org/pharmacy/Newsletters/2002/March%202002/Postoperative%20Nausea%20and%20Vomiting.htm </li></ul>