A Review of the Treatment for Postoperative Nausea and Vomiting

Submitted by Brianne Gallagher, RN, BSN, CCRN

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A Review of the Treatment for Postoperative Nausea and Vomiting

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Overview of Post-Operative Nausea and Vomiting (PONV) and Its Management

Post-operative nausea and vomiting (PONV) is a common side effect experienced by patients following anesthesia. It can range in severity from trivial to clinically significant, with the latter being defined as three or more vomits and/or a greater severity and duration of nausea.

PONV can lead to complications such as dehydration, electrolyte imbalance, wound dehiscence, pulmonary aspiration, and delayed hospital discharge. Risk factors for PONV include female gender, a history of PONV or motion sickness, non-smoking status, younger age, and the use of volatile anesthetics, among others.

PONV is a concern for both patients and healthcare professionals, with patients being more concerned about PONV than postoperative pain and willing to pay more to decrease its incidence. Nurses play a key role in the management of PONV, using various tools to provide relief and being aware of their approach in order to provide optimal patient care. A variety of pharmacological and non-pharmacological interventions can be used to prevent and treat PONV.

Written by Brianne Gallagher, RN, BSN, CCRN and Jayda Haag, RN, BSN

Postoperative nausea and vomiting (PONV) is a common undesirable side effect for patients undergoing anesthesia. Nausea and vomiting may occur in 70-80% of patients within the first 24 hours after surgery who have not received prophylactic treatment for PONV (Diemunsch et al., 2007). Approximately 30-40% of patients who receive a prophylactic administration of an antiemetic, such as ondansetron (a serotonin 5-HT 3 receptor antagonist), will still experience PONV (Diemunsch et al., 2007). PONV can cause complications such a dehydration, electrolyte imbalance, wound dehiscence, pulmonary aspiration and delayed hospital discharge (Cao, White & Ma, 2016). There are specific independent risk factors that are associated with an increased risk for postoperative nausea and vomiting. Some of these risk factors include female gender, history of PONV or motion sickness, non-smoker, younger age, duration of anesthesia with volatile anesthetics and postoperative opioids (Apfel et al., 2012).

The effects of PONV can range from trivial and transient to clinically significant. In order to define clinically significant PONV, 180 patients participated in a questionnaire utilizing a validated PONV intensity scale. The key factors in defining clinically important PONV were three or more vomits and/or a greater nausea severity and duration (Wengritzky, Mettho, Myles, Burke, & Kakos, 2010). The scale identified 29 patients (18%) as having clinically important PONV. Patients who experienced clinically significant PONV often had a lower quality recovery and required twice as much antiemetic treatment (Wengritzky, Mettho, Myles, Burke, & Kakos, 2010). A systematic review of twenty two studies (n = 95154), which included randomized controlled trials (RCTs) and large epidemiological observational studies that enrolled at least 500 adult patients (age ≥15 yr. old) and that identified independent predictors of PONV by means of multivariate logistic regression analysis, determined specific risk factors for PONV (Apfel et al., 2012). The female gender was the highest risk factor for developing PONV (OR 2.57, 95% confidence interval 2.32–2.84), followed by a history of PONV (2.09, 1.90–2.29), a non-smoking status (1.82, 1.68–1.98), a history of motion sickness (1.77, 1.55–2.04), and a younger age (0.88 per decade, 0.84–0.92). The use of volatile anesthetics was the strongest anesthesia-related predictor (1.82, 1.56–2.13), followed by the duration of anesthesia (1.46 h21, 1.30–1.63), postoperative opioid use (1.39, 1.20–1.60), and nitrous oxide (1.45, 1.06–1.98) (Apfel et al., 2012).

PONV is a primary concern for patients undergoing general anesthesia. A conjoint analysis study compared patients’ and health care professionals’ preferences in the postoperative period in regard to PONV and postoperative pain. Fifty-two health care professionals (anesthesiologists and recovery room nurses) and 200 women undergoing elective gynecological surgery participated in this study (Lee, Gin, Lau, & Ng, 2005). The results indicated that patients are more concerned about PONV than postoperative pain and are willing to have an increased out of pocket cost to ensure a decreased incidence for PONV (95% CI, 88%–91%) (Lee, Gin, Lau, & Ng, 2005). The anesthesia providers in this same study also demonstrated a high priority in decreasing the incidence of PONV, but not at an increased expense to their patients (95% CI, 85%–91%) (Lee, Gin, Lau, & Ng, 2005). Nurses are the primary care provider for patients in the postoperative period. A qualitative study interviewed 10 female nurses to illuminate the experience of nurses in relieving postoperative nausea and vomiting (Sussanne et al., 2010). The results indicate that nurse’s use different ‘tools’ to make PONV relief possible and the majority of nurses have the skills and knowledge to distinguish their patients’ needs (Sussanne et al., 2010). Nurses who are more aware of their approach in treating PONV have a better possibility in providing their patients with optimal patient care. Poor nursing care situations, such as an increased nurse to patient ratio which could lead to a decrease in the nurses ability to use their ‘tools’ properly, is associated with an increased incidence of PONV (Sussanne et al., 2010).

Guidelines recommend that patients with a moderate to high risk for developing PONV should receive prophylactic administration of an antiemetic (Gan et al., 2003). One of the most commonly used antiemetics in the clinical setting is ondansetron, a serotonin receptor antagonists (SRA). It binds to the 5-hydroxytryptamine subtype 3 (5-HT 3) receptors, selectively blocking the emetogenic stimula during anesthesia and surgery. Ondansetron has a proven efficacy and is recommended as a prophylactic antiemetic at the time of induction of anesthesia and post-operatively (Farhet, Pasha & Kazi, 2013). Ondansetron, when used as a prophylactic agent, is routinely administered approximately 15 to 30 minutes before the conclusion of the surgical procedure. Studies have shown that the prophylactic administration of ondansetron results in a 50-80% reduction of PONV in groups of low-risk patients but only a 25% reduction in patients identified as high risk for PONV (Pellegrini, DeLoge, Bennett & Kelly, 2009).

Due to the lack of effectiveness in preventing PONV in patients identified as high risk, some patients will often require a subsequent antiemetic for treatment. One of the most common agents used to treat this breakthrough PONV is the antiemetic agent promethazine. Promethazine is a dopamine receptor-blocking agent routinely administered because it has a rapid onset of action (within 3-5 minutes) and a relatively long duration of efficacy (approximately 2-6 hours) (Pellegrini, DeLoge, Bennett & Kelly, 2009). Promethazine works by changing the actions of chemicals in the brain. It also acts as an antihistamine. It blocks the effects of the naturally occurring chemical histamine in the body. However, unlike ondansetron, which has minimal side effects, promethazine is commonly associated with sedation, dry mouth and, in rare cases, hypotension (Pellegrini, DeLoge, Bennett & Kelly, 2009). Despite these side effects, many practitioners prefer promethazine to other traditional antiemetic agents because it can be used in the inpatient and outpatient settings (Pellegrini, DeLoge, Bennett & Kelly, 2009). Promethazine is routinely administered by the intravenous route to a patient while in the hospital setting, but it is also available in oral and suppository forms for outpatient administration (Pellegrini, DeLoge, Bennett & Kelly, 2009).

Dexamethasone is a corticosteroid that is often used prophylactically during surgery as well. According to Up To Date, it decreases inflammation by suppression of neutrophil migration, decreased production of inflammatory mediators and reversal of increased capillary permeability. It suppresses the normal immune response but the mechanism of antiemetic activity is unknown. There are concerns regarding its ‘potential’ complications (e.g., delayed wound healing, hyperglycemia, risk of infections) in selected ‘at risk’ patient populations (e.g., diabetics) (Cao, White & Ma, 2016).

Metoclopramide is frequently used to treat PONV postoperatively. Metoclopramide works by blocking dopamine receptors and can block serotonin receptors when higher doses are given, such as those for cancer patients. According to Up To Date, it also can enhance the response to acetylcholine of tissue in the upper GI tract causing enhanced motility and accelerated gastric emptying without stimulating gastric, biliary, or pancreatic secretions. It can also increase lower esophageal sphincter tone.

Scopolamine is an acceptable and cost-effective alternative to ondansetron as part of a multidrug prophylaxis regimen in patients with motion-induced emesis as well as high-risk patients undergoing major surgery (Cao, White & Ma, 2016). It is a centrally active anticholinergic drug that comes in the form of a patch placed behind the patient’s ear.

There are many treatment options available for treating PONV. As nurses, it is important to be knowledgeable of the different drugs and how they work. This helps registered nurses to be able to work with the physicians to determine the best treatment options for surgical patients. The combination of different drugs and alternative treatment measures, such as a cool cloth, deep breathing and inhalation of alcohol or aromatherapy, if available, will help nurses provide their patients with the most successful post-operative period possible.

References

  1. Apfel, C. C., Heidrick, F. M., Jukar-Rao, S., Jalota, L., Hornuss, C., Whelan, R. P.,…Cakmakkaya, O. S. (2012). Evidence-based analysis of risk factors for postoperative nausea and vomiting. British Journal of Anesthesia, 109, 742-753. Doi:10.1093/bja/anes276
  2. Cao, X., White, P. F., Ma, H. (2016). An update on the management of postoperativenausea and vomiting. Japanese Society of Anesthesiologists. doi:10.1007/s00540-017-2363-x
  3. Diemunsch, P., Gan, T. J., Philip, B. K., Girao, M. J., Eberhart, L., Irwin, M. G., …Lawson, F. C. (2007). Single-dose aprepitant vs ondansetron for the preventionof postoperative nausea and vomiting: a randomized, double-blind Phase III trial in patients undergoing open abdominal surgery. Brithis Journal of Anaesthesia, 99, 202-211. doi:10.1093/bja/aem133
  4. Farhat, K., Pasha, A. K., Kazi, W. A. (2013). Comparison of Ondansetron and metoclopramide for PONV prophylaxis in laparoscopic cholecystectomy. Journal of Anesthesia and Clinical Research, 4:297. doi: 10.4172/2155-6148.1000297
  5. Lee, A., Gin, T., Lau, A. S., & Ng, F. F. (2005). Anesthesia & Analgesia. A Comparison of Patients’ and Health Care Professionals’ Preference for Symptoms DuringImmediate Postoperative Recovery and the Management of Postoperative Nausea and Vomiting, 100, 87-93. doi: 10.1213/01.ANE.0000140782.04973.D9
  6. Pellegrini, J., DeLoge, J., Bennett, J., & Kelly, J. (2009) Comparision of inhalation of isopropyl alcohol vs promethazine in the treatment of postoperative nausea and vomiting (PONV) in patients identified as at high risk for developing PONV.AANA Journal, 77(4), 293-299.
  7. Sussanne, B., Arwestrom, C., Baker, A., & Bertero, C. (2010). Nurses’ experiences in the relief or postoperative nausea and vomiting. Journal of Clinical Nursing, 19, 1865-1972. doi: 10.1111/j.1365-2702.2009.03176.x
  8. Wengritzky, R., Mettho, T., Myles, P. S., Burke, J., & Kakos, A. (2010). Development and validation of a postoperative nausea and vomiting intensity scale. British Journal of Anesthesia, 104, 158-166. doi: 10.1093/bja/aep370