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A-PHARM- JT > PONV > Flashcards

PONV Flashcards

(50 cards)

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1
Q

What did Snow identify in 1848 related to anesthesia?

A

Severe nausea and vomiting associated with ether use, proposing wine and pharmacologic solutions. Estimated incidence was 75-80%

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2
Q

What is PONV described as in 1991?

A

The big ‘little problem’; patients with previous PONV reported nausea and vomiting as the most unpleasant component of surgery

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3
Q

Define nausea.

A

Subjectively unpleasant sensation in the epigastrium and throat associated with the urge to vomit

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4
Q

Define vomiting.

A

Forceful expulsion of upper gastrointestinal contents through the mouth caused by powerful sustained contraction of the abdominal muscles

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5
Q

Define retching.

A

Labored rhythmic activity of the respiratory muscles, including the abdominal muscles and diaphragm, without expulsion of gastric contents

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6
Q

What factors contribute to PONV?

A
  • Patient-specific
  • surgery-related
  • anesthetic-related
  • postoperative factors
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7
Q

What are patient-related factors?

A
  • Age—within pediatric population increase in incidence through pre-adolescence
  • Sex—women 2-3 times more likely to have PONV (fourfold increase during menses)
  • Obesity—BMI > 30 kg/m2 (fat is a reservoir for anesthetic agents)
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8
Q

What type of surgery has the highest incidence of PONV

A

Gynecologic surgery (65%)

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9
Q

Name some types of surgery that cause PONV

A
  • Gynecologic surgery - 65%
    Gynecologic laparotomy
    Dilatation and curettage of the uterus
  • Hernia repair/orchiopexy
  • Otolaryngologic surgery
    Middle ear
    Adentonsillectomy
  • Ophthalmologic surgery
    Strabismus repair - 76%
    Cataract
  • Dental extractions
  • Plastic/reconstructive procedures
    Breast procedures
    Skin and other
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10
Q

What are surgies that promote PONV

A
  • Gonadal/Reproductive
  • Abdominal
  • Oculo-gyric
  • Pharyngeal
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11
Q

What effect do benzodiazepines have on PONV?

A

Benzodiazepines decrease PONV

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12
Q

What is the effect of opioid analgesics on the CTZ?

A

Opioid analgesics stimulate the CTZ

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13
Q

How do NSAIDs help in relation to opioid use?

A

NSAIDs help decrease opioid use

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14
Q

Which types of anesthesia are associated with higher PONV risk?

A

General > major regional > peripheral regional

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15
Q

Which causes more PONV — inhalational agents or propofol-based anesthesia?

A

Inhalational agents > propofol-based

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16
Q

What is the effect of duration of anesthetic exposure on PONV?

A

Longer duration increases risk (60% risk after 30 minutes)

60% risk after 30 minutes

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17
Q

How does the experience of the anesthesia provider affect outcomes?

A

Greater experience is associated with fewer complications

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18
Q

What are postop factors that cause PONV

A
  • Uncontrolled pain, esp visceral/pelvic pain
  • Opioid administration
  • Early ambulation/patient handling
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19
Q

What are postop factors that help decrease PONV

A

Dehydration –> adequate IV fluid hydration can decrease PONV

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20
Q

How is early oral intake postop affect PONV

A

Early oral intake:
* Increases PONV after conventional surgery
* Decreases PONV after laparoscopic surgery

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21
Q

What are incidence of PONV

Study These Flashcards
A
  • 25% to 30% with general anesthesia *
  • Up to 80% with high risk procedures using emetogenic anesthetics (narcotics, desflurane)
22
Q

What are the down side of PONV?

Study These Flashcards
A
  • Estimates of PONV < actual occurrence *
  • Post-discharge PONV not well studied and may be under-treated
23
Q

What are the consequences of (PONV)?

Study These Flashcards
A
  • Patient discomfort (mild to severe)
  • Decreased ability to self-care
  • Increased costs (personnel, supplies, drugs, unplanned admissions)
  • Wound dehiscence/bleeding
  • Aspiration pneumonitis
  • Dehydration and electrolyte imbalance
24
Q

When is prophylactic antiemetic treatment indicated for PONV prevention?

Study These Flashcards
A

When a patient scores 3 or more points based on risk factors:

  • 3 points each: History of PONV, history of motion sickness, gynecologic laparoscopy, breast reconstruction
  • 2 points each: Facelift surgery, strabismus or middle ear surgery, neurosurgery, obesity
  • 1 point each: Preadolescent, female, anxiety, laparoscopic cholecystectomy, opioid use (intra/postop), anesthesia > 60 minutes
25
Which antiemetic drug classes and agents target dopamine (D), muscarinic (M), histamine (H), and serotonin (S) receptors, and how do their affinities vary?
* Anticholinergic: Scopolamine — M++++, D+, H+ * Antihistamines: Hydroxyzine, Dimenhydrinate, Diphenhydramine — H++++, M++, D+ * Benzamide: Metoclopramide — D+++, H+ * Butyrophenones: Droperidol, Haloperidol — D++++, H+ * 5-HT₃ Antagonists: Ondansetron, Dolasetron, Granisetron — S++++ * Phenothiazines: Promethazine — H++++, D++, M++, Prochlorperazine, Perphenazine — D++++
26
Which receptors does Scopolamine act on?
D: + M: ++++ H: +
27
Which receptors does Hydroxyzine/Dimenhydrinate/Diphenhydramine act on?
D: + M: ++ H: ++++
28
Which receptors does Metoclopramide act on?
D: +++ H: +
29
Which receptors does Droperidol and haloperidol act on?
D: ++++ H: +
30
Which receptors does Ondansetron/Dolasetron / Granisetron act on?
S: ++++
31
Which receptors does Promethazine act on?
D: ++ M: ++ H: ++++
32
Which receptors does Prochlorperazine act on?
D: ++++
33
Which receptors does Perphenazine act on?
D: ++++
34
What are the key pharmacokinetics and side effects of metoclopramide (one of benzamides) ?
* Rapidly absorbed orally; hepatic first-pass effect reduces bioavailability to ~75% * Distributed into most tissues and rapidly crosses the blood-brain barrier and placenta * Up to 30% excreted unchanged in urine; the rest excreted via urine/bile as sulfate and glucuronide conjugates * Half-life: 4–6 hrs (up to 24 hrs in pt with renal impairment) * Side effects: extrapyramidal symptoms and sedation Receptor D +++ , H +
35
What are the key properties and side effects of droperidol (a butyrophenone)? Elimination half life? Dose? Side effects?
* Elimination half-life ≈ 100 minutes * Doses as low as 0.625 mg have provided effects similar to 4 mg of ondansetron * Side effects: extrapyramidal symptoms, hypotension, prolonged tiredness, dysphoria, anxiety, and restlessness after discharge
36
What are phenothiazines (promethazine, prochlorperazine) most effective for, and what are their side effects?
* Most effective for treating opioid-associated PONV * Side effects: extrapyramidal symptoms and sedation
37
What is the black box warning for droperidol (Inapsine)?
Due to its risk of serious proarrhythmic effects and death, droperidol should be reserved for patients who do not respond to other adequate treatments, either due to lack of effectiveness or intolerable side effects from those treatments.
38
What precaution must be taken before administering droperidol (Inapsine)?
A 12-lead ECG must be performed to check for prolonged QT interval (QTc > 440 ms in males or > 450 ms in females). Droperidol should not be administered if QT prolongation is present due to the risk of serious arrhythmias (e.g. torsades de pointes).
39
What are the key properties, metabolism, efficacy, and side effects of 5HT3 receptor antagonists like ondansetron, granisetron, and dolasetron?
* 5HT3 receptor is the only one of 14 serotonin receptors which is a ligand-gated cation channel (like nicotine/GABA) * Readily absorbed orally with rapid CNS distribution * Metabolized by liver via cytochrome P450; eliminated via kidneys * Gernally well tolerated and effective even at low dose (ondansetron 1 mg, granisetron 100 mcg) * Side effects: headache, dizziness, constipation
40
What are the cardiac effects of 5-HT3 antagonists at high doses and how do they compare to droperidol?
* All have similar effects at high doses on cardiac conduction - only recognized in package inserts after Zofran introduction * * Effect is similar to droperidol effect! *
41
Why might some patients fail PONV prophylaxis with 5-HT3 antagonists?
* The wrong mechanism may be targeted (serotonin from the gut rather than narcotics) * Human variability in response
42
How does genetic variation influence the effectiveness of antiemetics like 5-HT3 antagonists?
* There are gene # and type variations for primary enzyme CYP2D6 * This may cause variable expression of metabolic enzymes amounts * Hypothesis is that genetic profile would correlate with PONV
43
What is the impact of the ultrarapid metabolizer phenotype on CYP2D6 activity and antiemetic drug effectiveness?
* Overactive CYP2D6 activity * Leads to reduced effectiveness of CYP2D6-metabolized 5-HT₃ receptor antagonists * Results in more nausea and vomiting despite standard dosing
44
What are the prevalence rates of the ultrarapid CYP2D6 metabolizer phenotype in different populations?
* Northern Europe: 2–4% * Mediterranean area: 7–12% * Ethiopia: 29% * Saudi Arabia: 21%
45
Patient populations with CYP2D6 deficiency
– 5%–10% of whites – Significant hepatic impairment – Coadministration of potent inhibitors, eg, quinidine, fluoxetine, or haloperidol
46
What are the clinical consequences of CYP2D6 deficiency?
– Increased potential for drug interactions and side effects – May result in accumulation of CYP2D6 metabolized drugs and higher serum drug concentrations of CYP2D6 5-HT₃
47
What are the key points about NK-1 antagonists in relation to PONV and therapy use?
– No indications yet for PONV – One drug (aprepitant) on market for CINV, others coming – Substance P binds to NK-1 and is blocked in CNS from doing so – Best in combination therapy (vs. as single agent) with 5HT-3 and steroids
47
What preoperative and antiemetic strategies are included in Scuderi’s Multimodal Therapy?
– Use of preoperative anxiolysis preventing air gulping – Three prophylactic anti-emetics (10 mg dexamethasone, 0.625 mg droperidol, and low dose of 5 HT-3) + gastric emptying
48
What anesthetic and analgesic agents are used in Scuderi’s Multimodal Therapy?
– TIVA (total intravenous anesthesia) using propofol induction/infusion – Non-lingering narcotics (eg. remifentanil) – Non-steroidals in place of narcotics (eg. ketorolac)
49
What intraoperative considerations are part of Scuderi’s Multimodal Therapy regarding N2O/inhaled anesthetics/muscle relaxants and hydration?
– No nitrous oxide or potent inhaled anesthetics – Avoidance of muscle relaxants/necessary reversal – Vigorous hydration

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