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PONV/GI Flashcards

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1
Q

How is “early” PONV defined?

A

occurs within the first 6 hours of surgery

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2
Q

How is “late” PONV defined?

A

occurs 6-24 hours after surgery

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3
Q

What is the incidence of PONV?

A

40% in general anesthesia
80% in high risk population

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4
Q

What patient factors put someone at risk for PONV?

A

female
non-smoker
hx of motion sickness
previous incidence of PONV

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5
Q

What surgical factors put a patient at risk for PONV?

A

long procedure
laparotomies, gyn sx, laparoscopic, ENT, breast, ortho

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6
Q

What anesthesia factors put a patient at risk for PONV?

A

inhalational agents
N2O
neostigmine
narcotics
etomidate

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7
Q

Where is the vomiting center located?

A

medulla oblongata

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8
Q

What are the 4 areas that trigger N/V?

A

chemoreceptor trigger zone
vestibular apparatus
thalamus & cerebral cortex
neurons in the GI tract

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9
Q

Describe the pathway of N/V

A

efferent signal travels via cranial nerves through vagal sympathetic fibers and parasympathetic chains that trigger a motor process to occur (emesis)

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10
Q

List the NT associated with PONV

A

dopamine
serotonin
acetylcholine
histamine
substance P

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11
Q

What receptors/NT play a role in PONV in the vestibular system?

A

H1 receptor (histamine)
M1 receptor (ACh)

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12
Q

What receptors/NT play a role in PONV in the CTZ?

A

chemoreceptors
D2 receptors (dopamine)
NK receptors (Substance P)
5-HT3 receptors (serotonin)

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13
Q

What receptors/NT play a role in PONV in the vomiting center?

A

H1 (histamine)
M1 (ACh)
NK (Substance P)
5-HT3 (serotonin)

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14
Q

What receptors/NT play a role in PONV in the GI tract?

A

mechanoreceptors (stretch)
chemoreceptors
5-HT3 (serotonin)
H1 (histamine)
NK (substance P)
M1 (ACh)

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15
Q

List the anticholinergics used to treat PONV

A

atropine
hyoscine
scopolamine

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16
Q

List the benzamides used to treat PONV

A

metoclopramide (Reglan)

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17
Q

List the benzos used to treat PONV

A

midazolam

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18
Q

List the butrophenones used to PONV

A

droperidol
haloperidol

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19
Q

List the cannabinoids used to treat PONV

A

dronabinol
nabilone

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20
Q

List the glucocorticoids used to treat PONV

A

dexamethasone

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21
Q

List the 5-HT3 antagonists used to treat PONV

A

dolasetron
granisetron
ondansetron
palonosetron
ramosetron
tropisetron

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22
Q

List the neurokinin-1 antagonists used to treat PONV

A

aprepitant
fosprepitant

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23
Q

List the phenothiazines used to treat PONV

A

prochoperazine
promethazine
chlorpromazine

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24
Q

How does scopolamine work to combat PONV?

A

-blocks transmission of impulses from vestibular apparatus to medulla

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25
What is the dose of scopolamine for PONV and how is it delivered?
5mcg/hr x 72 hours best if given at least 4 hours before stimulus transdermal delivery allows for slow and sustained dosing and prevents anticholinergic side effects
26
List the common uses for scopolamine
motion sickness middle ear surgery N/V with PCA or epidural morphine
27
Describe the MOA of metoclopramide for PONV
stimulates the GI tract via cholinergic and anti-dopaminergic effects -contracts lower esophageal sphincter & gastric fundus -increases gastric and small intestine motility -decreased muscle activity in pylorus & duodenum w/ stomach contraction
28
What populations should metoclopramide be cautiously used in and why?
Parkinson's RLS d/t anti-dopaminergic effects
29
What is the MOA of midazolam for PONV?
decrease synthesis & release of dopamine within the CTZ
30
When should midazolam be given for PONV?
at the end of the case
31
What is the MOA of droperidol for PONV?
competitive dopamine antagonist @ D2 receptor (blocks dopamine and GABA)
32
What is the dose of droperidol given for PONV?
0.625mg-1.25mg prophylactically
33
In which populations should droperidol be cautiously used?
Parkinson's RLS potential for prolonged QTc (high doses)
34
What is the MOA of dexamethasone for PONV?
inhibits prostaglandin synthesis and controls endorphin release
35
What is the typical dose of dexamethasone given for PONV?
4mg
36
In what patient populations should dexamthasone be cautiously used?
obese DM (increased r/f hyperglycemia)
37
What type of receptor is the 5-HT3 receptor? What NT acts on it?
ligand-gated (Na+ and K+) cation channel depolarizes the plasma membrane excitatory acted on by serotonin
38
Besides nausea, what other effects does serotonin have on the body?
addiction aggression vasoconstriction increased intestinal motility learning and memory consolidation
39
Why are 5HT-3 antagonists not useful for motion sickness or vestibular stimulation?
no 5HT-3 receptors located in those areas
40
What is the typical dose of ondansetron?
4mg, onset 30-60min
41
What are some side effects of ondansetron?
headache (major) diarrhea QTc prolongation
42
Which 5HT-3 antagonist has an active metabolite?
dolasetron
43
What is the typical dose of granisetron? How often is it dosed?
0.1mg lasts 24 hours
44
Which 5HT-3 antagonist is used to treat symptoms with carcinoid syndrome?
tropisetron
45
Describe Substance P
primary NT produced by pain & temp afferent peripheral neurons
46
What receptors does substance P act on and where are they located?
neurokinin (NK1, NK2, NK3) located in gut and nausea pathways
47
What is the MOA of aprepitant? What is the most common type of NV that it is used for?
competitive antagonist at NK1 receptors, inhibits substance P from binding used in chemotherapy-induced NV
48
What is a noteworthy side effect of aprepitant?
inhibition of steroidal contraceptives x 7-10 days
49
What is the MOA of phenothiazines? Give some examples
antagonize H1 and M1 receptors, preventing histamine and ACh from binding E.g. promethazine, procholoperazine, chlorpromazine
50
Histamine is synthesized from what substance?
histadine in the CNS, immune cells, and GI tract
51
Where are histamine receptors located?
H1: vascular smooth muscle, bronchial smooth muscle, CNS H2: stomach H3: presynaptic cleft
52
List examples of H1 receptor antagonists
diphenhydramine (Benadryl) hydroxyzine (Atarax, Vistaril) phenergan meclizine
53
What is the typical dosage/onset/duration of diphenhydramine?
dose: 25-50mg IV onset: 3 min (or less) duration: 1-7hrs
54
Describe dimenhydrinate
aka dramamine antagonizes H1 and M1 receptors used for motion sickness & sleep aid
55
What are some side effects of H1 receptor antagonists that are unrelated to the H1 blockade?
sedation anti-nausea/anti-emetic adrenoceptor blocking (esp Phenergan which may cause orthostatic hypotension)
56
What two methods are used to prevent aspiration?
antacids (increase gastric pH) prokinetics (decrease gastric fluid volume)
57
Is aspiration more or less common in pediatric patients?
more common (r/t use of inhaled anesthetics for induction??)
58
Which patient populations present with a higher r/f aspiration?
pregnant diabetic mask induction emergent case
59
What is the most common oral antacid given in anesthesia?
Bicitra 15-30mL given right before induction used in C-sections tastes awful
60
List the four H2 drugs currently available
cimetidine ranitidine famotidine nizatidine
61
What is the MOA of H2 blockers?
selective, reversible competition with histamine at H2 sites
62
What are the clinical uses for H2 receptor antagonists?
peptic duodenal ulcer gastric ulcer erosive esophagitis hypersecretory conditions
63
What are the s/s of H2 receptor antagonist toxicity?
CNS dysfunction (slurred speech, delirium, confusion) liver toxicity (mostly with cimetidine)
64
H2 receptor antagonists interact with which drugs?
inhibits the cytochrome P450 system (esp warfarin, dilantin, propranolol, metoprolol, labetalol, diazepam, CCBs)
65
List some commonly used PPIs
omeprazole pantoprazole esomerprazole lansoprazole
66
What effect do PPIs have on the body?
increase gastric fluid pH decrease gastric fluid volume *must be metabolized *can take days for effect *crosses BBB (HA, agitation, confusion)
67
Which drug is used to treat Zollinger-Ellison syndrome?
omeprazole
68
What do GI prokinetics do? List 2 examples
increase LES sphincter tone, enhance peristaltic contractions, accelerate the rate of gastric emptying E.g. metoclopramide, domperidone
69
What is the MOA of metoclopramide in the GI system?
involves cholinergic stimulation and dopamine antagonism -contract LES and gastric fundus (prevents reflux) -increase gastric emptying -decrease pylorus and duodenum muscle activity -crosses BBB and affects CTZ
70
What is the typical dose of metoclopramide?
10-30mg over 3-5 mins
71
What effect does metoclopramide have on gastric pH?
no effect
72
What are some side effects of metoclopramide?
crosses the placenta abdominal cramping if given fast extrapyramidal reactions (d/t dopaminergic effects) prolongs succs metabolism

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