ponv

1. Post operative nausea and
vomiting
Presenter - Dr Tanmay Patil
Moderator- Dr Ravi Khandelwal

2. DEFINITIONS
 VOMITING : Forceful expulsion of gastric contents
through mouth and nose
 NAUSEA : Sensation of unease and discomfort in stomach
with urge to vomit
 RETCHING : similar to vomiting with the exception that
no gastric content enters the pharynx.

3.  PONV is typically used to describe nausea and
vomiting or retching in post anaesthesia care unit
or in immediate 24 postoperative hrs.
 PONV can delay recovery room discharge or may
required unanticipated hospital stay.
 These can leads to rare but serious conditions like
wound dehiscence ,esophageal rupture,
aspiration, subcutaneous emphysema or
pneumothorax .

4. Introduction
 Without a prophylaxis, Postoperative nausea and
vomiting (PONV) occurs in approximately 20% to 30% of
general surgical population and up to 70-80% in patients
with predisposing risk factors.
 PONV is second most common (pain is most common)
complaint reported after surgery. As anesthetic
duration increases, so too, does PONV risk .
 When the risk is sufficiently great, prophylactic anti
emetic medications are administered and strategies to
reduce its incidence are initiated.
 Nausea and vomiting may be induced through various
pathways , which finally stimulate vomiting center in
brain stem.

11. Risk factors for postoperative
nausea and vomiting (PONV)
(1)Patient-specific risk factors:
-Female gender
-Nonsmoking status
-History of PONV/motion sickness
(2)Anesthetic risk factors:
-Use of volatile anesthetics
-Use of nitrous oxide
-Use of intraoperative and postoperative opioids
- Duration of anaesthesia.
(3)Surgical risk factors:
-Duration of surgery (each 30-min increase in duration
increases PONV risk by 60%, so that a baseline risk of
10% is increased by 16% after 30 min)
-Type of surgery -Laproscopic surgeries, ENT
surgeries,cholecystectomy,strabismus surgery.

12. Simplified risk score for adults PONV

14. RISK SCORE IN
PEADIATRICS
RISK FACTORS POINTS
SURG > 30 mins 1
Age >3 yrs 1
Strabismus surgery 1
History of POV or PONV in
relatives
1
Points score % risk of PONV
0 10%
1 10%
2 30%
3 50%
4 70%

18. Classification of anti emetics
(1)Dopamine antagonist -
metaclopromide,domperidone,droperidol,haloperidol,pr
oc-hlorperazine.
(2)Histamine antagonist-dimenhydrate, cyclizine,
promethazine.
(3)Anticholinergics- hyoscine(scopolamine).
(4)Serotonin antagonist- ondansetron, dolasetron,
granisetron, palonosetron.
(5)Glucocorticoids- dexamethasone.
(6)NK1(NEUROKININ) receptor antagonist- aprepitant.
(7)Others-propofol, midazolam, dexmedetomidine,clonidine

32. Combination and multimodal
therapy
 None of the currently available antiemetic is capable of
completely eliminating the incidence of PONV. The patients
baseline risk is main determent of the effectiveness of
antiemetic interventions.
 Therefore, prophylaxis is rarely justified in patients at low
risk, a single antiemetic is likely to be reasonable for
patients with a moderate risk, and patients at high risk are
likely to benefit from combination treatment.
 After administering an antiemetic, it is more effective to
choose an antiemetic of another class for later rescue
treatment.

34. Algorithm for management of
postoperative nausea and vomiting
TIVA
Preffered
Anticipated
rescue
1 risk
factor
2 risk
factors
3 risk
factors
4 risk
factors
YES Ondensetron Dexameth
-asone
+TIVA +D2-
receptor
antagonist
+Aprepitant
YES Non-5-HT3 Dexameth
-asone
+TIVA +Ondensetr-
on
+Aprepitant
NO Ondensetron Dexameth
-asone
+D2-
receptor
antagonist
+Aprepita-
nts
+TIVA
NO Non-5-HT3 Dexameth
-asone
Ondensetr
-on
+Aprepita-
nts
+TIVA

36. Thanks