CASE BASED LEARNING
BOOK CASE SCENRIO <ul><li>A 52 year old  </li></ul><ul><li>Anxious man. </li></ul><ul><li>Presents for revision of a previ...
QUESTIONS <ul><li>Is the anxious patient a good candidate for surgery under monitored anaesthesia care (MAC)? </li></ul><u...
<ul><li>Is the anxious patient a good candidate for surgery under monitored anaesthesia care (MAC)? </li></ul>
MAC <ul><li>MAC is a planned procedure during which the patient undergoes local anesthesia together with sedation and anal...
<ul><li>Able to answer to orders appropriately and to protect airways.  </li></ul><ul><li>Consciousness evaluation  </li><...
<ul><li>Retroauricular tympanoplasty and tympanomastoidectomy under local anesthesia with sedation can be well tolerated b...
SARMENTO KM JR ,  TOMITA S . <ul><li>Prospective study of 83 surgeries in 62 patients . </li></ul><ul><li>28 type I tympan...
<ul><li>Local infiltration - lidocaine 2% with 1:100 000 epinephrine infiltrated in the retroauricular area and from below...
<ul><li>The discomfort during surgery was assessed by the patient with a score from 0 to 4. </li></ul><ul><ul><li>0=no dis...
<ul><li>What general anaesthetic techniques are most likely to minimize postoperative nausea and vomiting (PONV)? </li></ul>
PONV <ul><li>30% - postoperative nausea and vomiting (PONV). </li></ul><ul><ul><ul><li>Anesthesiology 1992;77:162– 84. </l...
RISK FACTORS FOR PONV <ul><li>Age </li></ul><ul><li>Gender </li></ul><ul><li>Obesity </li></ul><ul><li>Surgical procedure ...
ANXIETY <ul><li>Increased anxiety before undergoing anesthesia and surgery is a risk factor for the development of PONV. <...
<ul><li>Operations in or around the ear are considered high risk for PONV – 70% </li></ul><ul><ul><ul><li>Anesth Analg 199...
<ul><li>Surgery in or around the ear may disturb the vestibular labyrinth, which (along with the chemoreceptor trigger zon...
ANTI-EMETIC CHOICES FOR PONV <ul><li>Promethazine - phenothiazine, has predominantly antidopaminergic effects with moderat...
<ul><li>Ondansetron, a 5-HT3 receptor antagonist,  decreased PONV after tympanoplasty. </li></ul><ul><ul><ul><li>Can J Ana...
<ul><li>A combination of antiemetics that have differing receptor sites may produce better results than either drug alone....
<ul><li>Propofol infusion reduces PONV as compared to volatile anesthetics. </li></ul><ul><ul><ul><li>Anesthesiology 1999;...
<ul><li>Opioid-sparing techniques, including the use of other analgesics such as nonsteroidal antiinflammatory drugs and r...
NON PHARMACOLOGIC TREATMENTS <ul><li>Acupuncture, electroacupuncture, transcutaneous electrical nerve stimulation, acupoin...
TYMPANO-MASTOIDECTOMY <ul><li>Tympanoplasty and mastoidectomy. </li></ul><ul><li>Middle ear surgery. </li></ul><ul><ul><li...
CONDUCT OF GA FOR MIDDLE EAR SURGERY <ul><li>Anesthesia is induced with a hypnotic and short-acting muscle relaxant or by ...
<ul><li>Antiemetics should be given because postoperative vomiting is very common with ear surgery  </li></ul>
<ul><li>Are regional anesthetics less likely to result in PONV in this patient? </li></ul>
<ul><li>Regional anesthesia rather than general anesthesia should be used when possible. </li></ul>
<ul><li>Why is control of blood loss important during middle ear surgery? </li></ul>
BLOODLESS FIELD <ul><li>Delicate microsurgery of the ear requires adequate hemostasis. </li></ul><ul><li>Volatile anesthet...
<ul><li>Are long-acting neuromuscular blocking agents contraindicated in middle ear surgery? </li></ul>
Upcoming SlideShare
Loading in...5
×

PONV

2,363

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
2,363
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
59
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

PONV

  1. 1. CASE BASED LEARNING
  2. 2. BOOK CASE SCENRIO <ul><li>A 52 year old </li></ul><ul><li>Anxious man. </li></ul><ul><li>Presents for revision of a previous tympano-mastoidectomy on an </li></ul><ul><li>Ambulatory basis. </li></ul><ul><li>The patient is otherwise in good general health. </li></ul><ul><li>He has undergone several previous procedures </li></ul><ul><li>Resulted in post operative nausea and vomiting. </li></ul>
  3. 3. QUESTIONS <ul><li>Is the anxious patient a good candidate for surgery under monitored anaesthesia care (MAC)? </li></ul><ul><li>What general anaesthetic techniques are most likely to minimize postoperative nausea and vomiting (PONV)? </li></ul><ul><li>Are regional anesthetics less likely to result in PONV in this patient? </li></ul><ul><li>Why is control of blood loss important during middle ear surgery? </li></ul><ul><li>Are long-acting neuromuscular blocking agents contraindicated in middle ear surgery? </li></ul>
  4. 4. <ul><li>Is the anxious patient a good candidate for surgery under monitored anaesthesia care (MAC)? </li></ul>
  5. 5. MAC <ul><li>MAC is a planned procedure during which the patient undergoes local anesthesia together with sedation and analgesia - (ASA). </li></ul><ul><ul><ul><li>ASA Newsletter 1998;62(12). </li></ul></ul></ul><ul><li>First choice in 10-30% of all the surgical procedures. </li></ul><ul><li>The 3 fundamental elements of conscious sedation are: </li></ul><ul><ul><li>A safe sedation </li></ul></ul><ul><ul><li>The control of the patient anxiety </li></ul></ul><ul><ul><li>The pain control. </li></ul></ul><ul><ul><ul><li>MINERVA ANESTESIOL 2005;71:533-8 </li></ul></ul></ul>
  6. 6. <ul><li>Able to answer to orders appropriately and to protect airways. </li></ul><ul><li>Consciousness evaluation </li></ul><ul><ul><li>Clinical </li></ul></ul><ul><ul><li>BIS. </li></ul></ul><ul><li>Discharge - fast. </li></ul><ul><ul><ul><ul><ul><li>MINERVA ANESTESIOL 2005;71:533-8 </li></ul></ul></ul></ul></ul>
  7. 7. <ul><li>Retroauricular tympanoplasty and tympanomastoidectomy under local anesthesia with sedation can be well tolerated by the patient, with minimum discomfort. </li></ul>
  8. 8. SARMENTO KM JR , TOMITA S . <ul><li>Prospective study of 83 surgeries in 62 patients . </li></ul><ul><li>28 type I tympanoplasties, 12 tympanoplasties with ossicular reconstruction, 40 canal wall up mastoidectomies, and 3 revision tympanoplasties. </li></ul>
  9. 9. <ul><li>Local infiltration - lidocaine 2% with 1:100 000 epinephrine infiltrated in the retroauricular area and from below the pinna. </li></ul><ul><li>Sedation was achieved with 50mg of intramuscular promethazine 1h before surgery and intravenous midazolam (0.03mg/kg) at the beginning of surgery. </li></ul><ul><li>Subsequent doses of midazolam were given to maintain adequate sedation, up to 10mg. </li></ul>
  10. 10. <ul><li>The discomfort during surgery was assessed by the patient with a score from 0 to 4. </li></ul><ul><ul><li>0=no discomfort and 4=extreme discomfort). </li></ul></ul><ul><li>Discomfort due to pain had a mean score of 0.83. </li></ul><ul><li>Noise discomfort (from drilling and manipulation of instruments) had the lowest mean score (0.70), </li></ul><ul><li>Discomfort from body and neck position had the highest mean score (1.51). </li></ul><ul><ul><ul><li>Acta Otolaryngol. 2008 Sep 11:1-3 </li></ul></ul></ul>
  11. 11. <ul><li>What general anaesthetic techniques are most likely to minimize postoperative nausea and vomiting (PONV)? </li></ul>
  12. 12. PONV <ul><li>30% - postoperative nausea and vomiting (PONV). </li></ul><ul><ul><ul><li>Anesthesiology 1992;77:162– 84. </li></ul></ul></ul>
  13. 13. RISK FACTORS FOR PONV <ul><li>Age </li></ul><ul><li>Gender </li></ul><ul><li>Obesity </li></ul><ul><li>Surgical procedure (Ear surgery). </li></ul><ul><li>History of motion sickness or PONV. </li></ul><ul><ul><ul><li>Br J Anaesth 1996;76:347–51. </li></ul></ul></ul><ul><li>Anxiety. </li></ul>
  14. 14. ANXIETY <ul><li>Increased anxiety before undergoing anesthesia and surgery is a risk factor for the development of PONV. </li></ul><ul><ul><ul><li>Anesthesiology 1992;77: 162–84. </li></ul></ul></ul>
  15. 15. <ul><li>Operations in or around the ear are considered high risk for PONV – 70% </li></ul><ul><ul><ul><li>Anesth Analg 1996;82:S37. </li></ul></ul></ul><ul><ul><ul><li>Anaesthesia 1997;52:544–6. </li></ul></ul></ul><ul><li>47% of 162 adults who had middle ear or mastoid surgery experienced PONV. </li></ul><ul><li>Remained significantly longer in PACU than patients who did not have this complication. </li></ul><ul><ul><ul><li>Anesth Analg 1996;82:S37 </li></ul></ul></ul>
  16. 16. <ul><li>Surgery in or around the ear may disturb the vestibular labyrinth, which (along with the chemoreceptor trigger zone) incites the vomiting center. </li></ul><ul><li>The trigger zone is located in the area postrema (near the trigonum of the vagus nerve), which contains a high concentration of 5-HT3 receptors. </li></ul><ul><li>The vomiting reflex may be activated when serotonin stimulates the vagal afferents through the 5-HT3 receptors. </li></ul><ul><ul><ul><li>J. Clin. Anesth., vol. 11, November 1999 </li></ul></ul></ul>
  17. 17. ANTI-EMETIC CHOICES FOR PONV <ul><li>Promethazine - phenothiazine, has predominantly antidopaminergic effects with moderate antihistaminic and anticholinergic properties. </li></ul><ul><li>It has been recommended as an antiemetic for patients having ear surgery. </li></ul><ul><li>Promethazine can cause significant sedation and lethargy. </li></ul><ul><ul><ul><li>Can Anaesth Soc J 1984;31:407–15. </li></ul></ul></ul>
  18. 18. <ul><li>Ondansetron, a 5-HT3 receptor antagonist, decreased PONV after tympanoplasty. </li></ul><ul><ul><ul><li>Can J Anaesth 1996;43:939–45. </li></ul></ul></ul><ul><li>Scopolamine. </li></ul><ul><li>Droperidol. </li></ul><ul><ul><li>Prolongation of the QT interval. </li></ul></ul><ul><li>Dexamethasone. </li></ul><ul><ul><ul><li>Anesth Analg 2000;90:186-94 </li></ul></ul></ul><ul><li>Metochlopramide. </li></ul>
  19. 19. <ul><li>A combination of antiemetics that have differing receptor sites may produce better results than either drug alone. </li></ul><ul><li>The combination of promethazine and ondansetron significantly reduces the incidence of PONV during the first 24 hours after middle ear surgery. </li></ul><ul><li>The combination reduces significantly the severity of vomiting. </li></ul><ul><ul><ul><li>Anesth Analg 1996;83:117–22. </li></ul></ul></ul>
  20. 20. <ul><li>Propofol infusion reduces PONV as compared to volatile anesthetics. </li></ul><ul><ul><ul><li>Anesthesiology 1999;91:253-61. </li></ul></ul></ul><ul><li>Nitrous increases PONV. </li></ul><ul><ul><ul><li>Anesthesiology 1996;85: 1055-62. </li></ul></ul></ul><ul><li>TIVA with propofol in place of a volatile anesthetic and nitrous oxide is equivalent to the use of a volatile anesthetic with a prophylactic antiemetic drug. </li></ul><ul><ul><ul><li>N Engl J Med 2004;350:2441-51. </li></ul></ul></ul>
  21. 21. <ul><li>Opioid-sparing techniques, including the use of other analgesics such as nonsteroidal antiinflammatory drugs and regional blocks. </li></ul><ul><li>Do not use high dose neostigmine (>2.5mg). </li></ul><ul><li>Hydration with 20 mL/kg of appropriate intravenous fluid preoperatively significantly decreases postoperative nausea on day 1 . </li></ul><ul><ul><ul><li>Anesth Analg 1995;80:682-6. </li></ul></ul></ul>
  22. 22. NON PHARMACOLOGIC TREATMENTS <ul><li>Acupuncture, electroacupuncture, transcutaneous electrical nerve stimulation, acupoint stimulation, and acupressure. </li></ul><ul><ul><li>Similar to pharmacologic agents in preventing early and late vomiting. </li></ul></ul><ul><ul><ul><li>Anesth Analg 1999;88:1362-9. </li></ul></ul></ul><ul><li>Acupressure wristbands may be effective in preventing PONV after short surgical procedures when applied prior to emetic stimulus exposure. </li></ul><ul><ul><ul><li>Anesth Analg 1997;84:821-5. </li></ul></ul></ul>
  23. 23. TYMPANO-MASTOIDECTOMY <ul><li>Tympanoplasty and mastoidectomy. </li></ul><ul><li>Middle ear surgery. </li></ul><ul><ul><li>Still operative field, </li></ul></ul><ul><ul><li>Minimal bleeding. </li></ul></ul>
  24. 24. CONDUCT OF GA FOR MIDDLE EAR SURGERY <ul><li>Anesthesia is induced with a hypnotic and short-acting muscle relaxant or by inhalation. </li></ul><ul><li>Maintainence with a volatile anesthetic. </li></ul>
  25. 25. <ul><li>Antiemetics should be given because postoperative vomiting is very common with ear surgery </li></ul>
  26. 26. <ul><li>Are regional anesthetics less likely to result in PONV in this patient? </li></ul>
  27. 27. <ul><li>Regional anesthesia rather than general anesthesia should be used when possible. </li></ul>
  28. 28. <ul><li>Why is control of blood loss important during middle ear surgery? </li></ul>
  29. 29. BLOODLESS FIELD <ul><li>Delicate microsurgery of the ear requires adequate hemostasis. </li></ul><ul><li>Volatile anesthetics and/or vasodilators. </li></ul><ul><li>MAP – 60-70mm Hg. </li></ul><ul><li>Elevation of the head of the bed to approximately 15° to decrease venous congestion and local application of epinephrine for vasoconstriction usually improve operating conditions. </li></ul>
  30. 30. <ul><li>Are long-acting neuromuscular blocking agents contraindicated in middle ear surgery? </li></ul>
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×