PONV (Mordecai) Exam III

Question 1

What is the most common patient complaint postoperatively, as mentioned in the slide?

A) Nausea
B) Vomiting
C) Pain
D) Dizziness

Answer 1

B) Vomiting

Slide 3

Question 2

What is the overall incidence of postoperative nausea and vomiting?

A) 10-20%
B) 20-30%
C) 30-40%
D) 50-60%

Answer 2

B) 20-30%

Some studies reach as high as 80%

Slide 3

Question 3

When does postoperative vomiting typically peak?

A) 1 hour postop
B) 3 hours postop
C) 6 hours postop
D) 12 hours postop

Answer 3

C) 6 hours postop

Slide 3

Question 4

The incidence of intractable vomiting is ________.

A) 0.1%
B) 0.12%
C) 0.15%
D) 1.0%

Answer 4

A) 0.1%

most severe, the severe end of the spectrum

Intractable = hard to control or deal with

Slide 3

Question 5

Postoperative vomiting can persist for ________.

A) 6-12 hours
B) 12-24 hours
C) 24-48 hours
D) 48-72 hours

Answer 5

C) 24-48 hours

Question 6

True or False

The cause of PONV is well understood and we have identified multiple receptor sites that are targeted to help mitigate the severity of the PONV.

Answer 6

False

Mordecai - The cause of PONV is not thoroughly understood by us but we have identified multiple receptor sites that are implicated in PONV and we target those receptor sites to help mitigate the severity of the PONV.

Slide 3

Question 7

Which of the following are patient-specific risk factors for PONV? Select 4

A) Non-smokers
B) Female gender
C) Enhanced gastric emptying
D) History of PONV
E) History of diabetes
F) History of motion sickness

Answer 7

A) Non-smokers
B) Female gender
D) History of PONV
F) History of motion sickness - history of sickness in vehicles, on cruises, on fishing trips, in airplanes..

I’m on a boat..

Slide 4

Question 8

Select the factors that are associated with an increased risk of PONV:
Select 2

A) Preoperative anxiety
B) Delayed gastric emptying
C) Male gender
D) Smokers

Answer 8

A) Preoperative anxiety
B) Delayed gastric emptying - patients with gastroparesis related to diabetes or autoimmune gastroparesis disorders

Slide 4

Question 9

Which of the following anesthetic agents is associated with an increased risk of postoperative nausea and vomiting (PONV)?

A) Propofol
B) Volatile anesthetics
C) Ketamine
D) Fentanyl

Answer 9

B) Volatile anesthetics

Slide 5

Question 10

Gastric distention during surgery, often caused by the use of ________, can contribute to the risk of PONV.

A) Nitrous oxide
B) Volatile anesthetics
C) Propofol
D) Neostigmine

Answer 10

A) Nitrous oxide

M - Studies show that Nitrous oxide in concentrations greater than 50% have a positive coorelation with nausea and vomiting, so avoid in patients with hx of PONV

slide 5

Question 11

Select the things that are commonly associated with increased risk of PONV:
Select 3

A) Intra/Postop opioids
B) Non-volatiles
C) Postoperative opioids only
D) Local anesthetics
E) Preanesthesic medications
F) Duration of anesthesia

Answer 11

A) Intra/Postop opioids
E) Preanesthesic medications
F) Duration of anesthesia

M - The duration of anesthesia is associated with more nausea, probably because the longer the patient is under anesthesia, the more likely in the higher doses of exposure to volatile anesthetics and opioids and other drugs

Slide 5

Question 12

Which of the following agents or situations can increase the risk of PONV in the postoperative period? Select 3

A) Neostigmine
B) Gastric distention
C) Propofol
D) Mandatory oral fluids before discharge
E) Postanesthetic medication
F) Sugammadex

Answer 12

A) Neostigmine
B) Gastric distention
D) Mandatory oral fluids before discharge

M - we know neostigmine increases free acetylcholine, and that is associated with nausea. We want to avoid excessive uses of neuromuscular blockers that will require high doses of neostigmine to reverse at the end of the case.

More recently we’re leaning heavier on sugammadex in situations where the patient has a history of PONV

Slide 5

Question 13

Which type of surgery is considered high-risk for PONV?

A) Cataract surgery
B) Laparoscopy
C) Dermatologic surgery
D) Urologic surgery

Answer 13

B) Laparoscopy

M - laparoscopic surgery…this is where we’re insufflating the stomach and causing that CO2 gas is going to put pressure on the GI system and can cause some discomfort and nausea from that.

Slide 6

Question 14

Which types of surgeries are linked to a higher incidence of PONV due to being close to the chemoreceptor trigger zone (CTZ) and emetic center? Select 2

A) Ear, nose, throat surgery
B) Breast surgery
C) Plastic surgery
D) Cataract surgery
E) Neurosurgery

Answer 14

A) Ear, nose, throat surgery (ENT)
E) Neurosurgery

slide 6

Question 15

Which of the following surgical factors are associated with an increased risk of PONV?
Select 3

A) Amputation
B) Laparotomy
C) Breast or plastic surgery
D) TIVA
D) Shorter duration of surgery
F) Strabismus

Answer 15

B) Laparotomy
C) Breast or plastic surgery
F) Strabismus

M - ...plastic surgery may be due to the fact that the patient population being younger females, not really clear…and so a lot of times we will do a propofol TIVA on these patients.

Slide 6

Question 16

Which of the following is true regarding the risk of postoperative nausea and vomiting (PONV) in pediatric patients? (Select 2 all that apply)

A) The risk increases with age until puberty
B) The risk decreases with age until puberty
C) Males are at higher risk than females
D) The risk is twice that of adults

Answer 16

A) The risk increases with age until puberty
D) Risk is twice that of adults

Slide 7

Question 17

The risk of PONV in pediatric patients is ________ that of adults.

A) Equal to
B) Twice
C) Half
D) Three times

Answer 17

B) Twice

slide 7

Question 18

Which of the following are true regarding PONV risk factors in pediatric patients?

A) Risk increases with age until mid-life crisis
B) Male and female patients have equal risk
C) Vomiting is twice as common as in peds
D) Risk decreases after puberty

Answer 18

B) Male and female patients have equal risk

Slide 7

Question 19

Which of the following pediatric procedures are associated with an increased risk of PONV? Select 3

A) Orchiopexy
B) Arthroscopy
C) Strabismus repair
D) Hernia repair
E) Appendectomy

Answer 19

A) Orchiopexy
C) Strabismus repair
D) Hernia repair

Slide 7

Question 20

Which of the following pediatric procedures are associated with a higher risk of PONV?
Select 2

A) Adenotonsillectomy
B) Orthopedic repair
C) Dental repair
D) Penile surgery
E) Rhinoplasty

Answer 20

A) Adenotonsillectomy
D) Penile surgery

Slide 7

Question 21

Which of the following are effective strategies for reducing the incidence of PONV?
Select 2

A) Avoiding volatile anesthetics
B) Using steriods
C) Giving nitrous
D) Using propofol TIVA
E) Delaying ambulation after surgery

Answer 21

A) Avoiding volatile anesthetics
D) Using propofol TIVA

M - …we try reducing our volatile anesthetics, so we’ll try to rely more heavily on regional anesthesia and propofol induction TIVA. for anybody that is known to have high risk factors or have a history of PONV.

Helpful Mordecai Hints
Lets say you’re doing a long case, 5-6hr hour mommy makeover for a plastic surgeon. One option is to use your volatile anesthetics and then at the last hour of the case, switch over to a TIVA. Some studies show that’s actually almost as effective as doing a TIVA for the duration of the anesthetic.

Slide 8

Question 22

What are effective strategies to minimize PONV during surgery?
Select 3

A) Regional anesthesia
B) Maximizing opioid use
C) Intraoperative supplemental O2
D) High doses of neostigmine
E. Adequate hydration

Answer 22

A) Regional anesthesia
C) Intraoperative supplemental O2
E. Adequate hydration

Slide 8

Question 23

Which strategies are recommended to reduce the risk of PONV?
Select 2

A) Turning volatile on at end of case
B) Local Anesthetic infiltration
C) Non-steroidals
D) Limiting oxygen supplementation

Answer 23

B) Local Anesthetic infiltration
C) Non-steroidals

M - We want to minimize our opioids, and so we lean on multimodal type medications, like Tylenol and Precedex, and infiltrating the surgical wound with local anesthetics, so that would be the surgeon helping us out there, and non -steroidal medications as well.

Slide 8

Question 24

What are effective strategies to minimize PONV during surgery?
Select 2

A) Minimize motion, early ambulation
B) Minimizing suggamadex
C) IM injections of Local Anesthetic
D) Minimize neostigmine

Answer 24

A) Minimize motion, early ambulation
D) Minimize neostigmine

M - it’s important to get them moving, but it needs to be kind of a slow and steady process, just like with the fluid intake. If they get up and moving too quickly, then that can be nausea inducing as well. So no forced ambulation.

Slide 8

Question 25

Which of the following are consequences of PONV in surgical patients? Select 3 A) Tension on suture lines B) Wound strengthening C) Aspiration D) Decreased intraocular pressure E) Dehydration and electrolyte imbalance

Answer 25

A) Tension on suture lines C) Aspiration E) Dehydration and electrolyte imbalance ## Footnote Slide 9

Question 26

Which factors related to PONV can increase hospital costs? Select 3 A) Prolonged PACU stay B) Wound dehiscence C) Anticipated admissions D) Reduced surgical time E) Increased need for personnel F) Relaxed suture lines

Answer 26

A) Prolonged PACU stay B) Wound dehiscence E) Increased need for personnel *and resources* M - *then if wound dehiscence occurs, then you have to worry about infection, use of antibiotics, unnecessary use of antibiotics, and then the potential for antibiotic resistance.* *...whenever the patients are in PACU longer than anticipated, this can cause a backup and delay in new fresh post -op patients coming to recovery because there may not be room for them. This delays their time, and it actually adds to their operating room time, **which will add to their cost of surgery.*** ## Footnote Slide 9

Question 27

What are some reasons we care about preventing PONV? Select 3 A) Increased intracranial pressure B) Short PACU stay C) Unanticipated admissions D) Overhydration and electrolyte balance E) Increased intraocular pressure

Answer 27

A) Increased intracranial pressure C) Unanticipated admissions E) Increased intraocular pressure ## Footnote Slide 9

Question 28

Where is the emetic center located? A) Cerebral cortex B) Cerebellum C) Lateral reticular formation D) Hypothalamus

Answer 28

C) Lateral reticular formation of *the brainstem* ## Footnote Slide 10

Question 29

# True of False Medications act directly on the emetic center to cause nausea

Answer 29

False No substances act directly on the emetic center ## Footnote Slide 10

Question 30

Which structures are involved in sending *afferent* input to the emetic center? Select 3 A) Mediastinum B) Larynx C) GI tract D) Vestibular portion of the 9th CN E) Pharynx

Answer 30

A) Mediastinum C) GI tract E) Pharynx ## Footnote Slide 10

Question 31

A primary source of afferent input to the emetic center from higher brain centers is in the chemoreceptor trigger zone from ________. A) Area postrema B) Cerebral cortex C) Olfactory nerve D) Pons

Answer 31

A) Area postrema ## Footnote Slide 10

Question 32

Afferent input from the higher brain centers comes from the vestibular portion of the ________ cranial nerve. A) 5th B) 8th C) 10th D) 7th

Answer 32

B) 8th ***Vestibulo**cochlear Nerve* ## Footnote Slide 10

Question 33

Why is the chemoreceptor trigger zone (CTZ) particularly sensitive to chemicals and drugs? A) It has a dense blood-brain barrier B) It lacks a blood-brain barrier C) It is located in the spinal cord D) It only responds to physical stimuli

Answer 33

B) It lacks a blood-brain barrier M - *receptors in this area are sensitive to a variety of neurotransmitters, a **variety of chemicals and drugs in the blood or CSF can trigger this area.*** ## Footnote Slide 11

Question 34

Which of the following receptor types are **NOT** involved in triggering the CTZ's response to nausea and vomiting? A) Dopamine B) 5-HT3 C) Muscarinic D) Opioid E) Alpha-adrenergic F) Cannabinoid

Answer 34

E) Alpha-adrenergic **Refresher:** *5-HT3's are a subtype of serotonin receptor (5-HT) that are found in the central nervous system and in the gastrointestinal tract* ## Footnote Slide 11

Question 35

Which of the following receptor types are involved in triggering the CTZ's response to nausea and vomiting? Select 3 A) Histamine B) GABA C) Neurokinin-1 D) Serotonin E) Leukotrienes

Answer 35

A) Histamine C) Neurokinin-1 D) Serotonin (5-HT) ## Footnote Slide 11

Question 36

Which of the following are **NOT** true about the studies on PONV management? Select 3 A) They have a large effect size B) They are poorly powered C) They lack standardization D) They provide a definitive gold standard drug E) They show consistent outcomes across trials

Answer 36

A) They have a large effect size D) They provide a definitive gold standard drug E) They show consistent outcomes across trials Numerous studies showed: * Poor effect size * Poorly powered * Lack standardization ## Footnote Slide 13

Question 37

No single drug is considered a ________ for PONV management. A) Failure B) Gold standard C) Non-effective option D) First-line choice

Answer 37

B) Gold standard ## Footnote Slide 13

Question 38

Which statements about PONV management are accurate? Select 2 A) Patients should not receive the same drug for prophylaxis and treatment B) There are multiple gold standard drugs to choose from for PONV C) Patients should receive the same drug for both prophylaxis and treatment D) Work should focus on identifying and preventing PONV rather than treating it E) Standardization is present in most studies

Answer 38

A) Patients should not receive the same drug for prophylaxis and treatment D) Work should focus on identifying and preventing PONV rather than treating it ## Footnote Slide 13

Question 39

When patients received one antiemetic, the incidence of PONV dropped to approximately: A) 38% B) 50% C) 28% D) 20%

Answer 39

A) 38% ## Footnote Slide 14

Question 40

The use of two antiemetics resulted in an incidence of approximately ________. A) 50% B) 38% C) 28% D) 20%

Answer 40

C) 28% ## Footnote Slide 14

Question 41

What was the incidence of PONV when ALL three antiemetics (Ondansetron, Dexamethasone, Droperidol) were used at the same time? A) 38% B) 50% C) 28% D) 20%

Answer 41

D) 20% M - *if the patient received all three drugs, so Zofran, dexamethasone, droparadol, they saw that it dropped to around 20%. So significant improvement when you're tacking on different drugs that target different receptors.* ## Footnote Slide 14

Question 42

Which of the following increases the risk of PONV when used for sedation? A) Opioid premedication B) Benzodiazepines (BZD) C) Tylenol D) Propofol

Answer 42

A) Opioid premedication ## Footnote Slide 15

Question 43

Benzodiazepines may ________ the risk of PONV when used as sedation. A) Increase B) Have no effect on C) Decrease D) Exacerbate

Answer 43

C) Decrease ## Footnote Slide 15

Question 44

Which of the following can increase the risk of PONV during induction? Select 3 A) Ketamine B) Benzodiazepines C) Volatile anesthetics D) Etomidate E) Propofol

Answer 44

A) Ketamine C) Volatile anesthetics D) Etomidate *Propofol ↓…short duration; better if used induction and maintenance* M - *a little bit of propofol will have a dramatic effect on PONV, and so it can be run at a low sub-hypnotic dose in the background throughout a case while volatile anesthetics are being used, and that can help as well if you don't want to use the full TIVA dose of propofol* ## Footnote Slide 15

Question 45

Which of the following are true regarding the use of nitrous oxide in PONV prevention? Select 2 A) It is associated with an increased risk of PONV B) It is safe to use in high risk patients C) Concentrations greater than 50% increase PONV D) It decreases the need for antiemetic drugs E) It is more effective than Propofol for PONV prevention

Answer 45

A) It is associated with an increased risk of PONV C) Concentrations greater than 50% increase PONV ## Footnote Slide 15

Question 46

# True or False A single dose of morphine is associated with increased PONV

Answer 46

True ## Footnote Slide 16

Question 47

What is one strategy for opioid avoidance to reduce PONV risk? A) Using high doses of morphine B) Utilizing regional nerve blocks C) Increasing the use of opioids for pain management D) Administering low doses of ketamine

Answer 47

B) Utilizing regional nerve blocks ## Footnote Slide 16

Question 48

Which strategies are recommended to **reduce** PONV? Select 2 A) Single dose of morphine B) Forcing ambulation C) High-dose acetaminophen D) Wound infiltration with local anesthetics E) Increased ketamine use

Answer 48

C) High-dose acetaminophen D) Wound infiltration with local anesthetics ## Footnote Slide 16

Question 49

Which nursing interventions do we want to **avoid** and help reduce PONV risk? Select 3 A) Forcing position changes B) Forcing ambulation C) Doing slow movements D) Keeping the patient immobile postoperatively E) Forcing early postoperative oral fluids

Answer 49

A) Forcing position changes B) Forcing ambulation E) Forcing early postoperative oral fluids ## Footnote Slide 16

Question 50

Which of the following are associated with the use of anticholinesterases or NMBD reversal drugs? A) Increased muscarinic actions on the GI tract B) Decreased motility and secretions C) Decreased muscarinic actions on the GI tract D) Risk of aspiration PONV is decreased

Answer 50

A) Increased muscarinic actions on the GI tract **Refresher:** Anticholinesterases (like Neostigmine), which are drugs that inhibit the enzyme AChe, increase the activity of the muscarinic receptors in the gastrointestinal (GI) tract, causing a number of effects, including increased motility and secretions ## Footnote Slide 16

Question 51

At what dose of neostigmine is there an increased risk of PONV? A) 0.5 mg B) 1 mg C) 2 mg D) 2.5 mg

Answer 51

D) **Greater than** 2.5 mg M - *studies show neostigmine >2.5mg is more likely to be nausea inducing. But usually when you give neostigmine and you're using it as a reversal, you're going to give more like 4-5mg, its not often you are giving less than 2.5mg* ## Footnote Slide 16

Question 52

Atropine is administered with neostigmine to ________ the risk of PONV. A) Increase B) Maintain C) Reduce D) Neutralize

Answer 52

C) Reduce M - *Atropine is known to reduce PONV. So if you're going to have to use Neostigmine, you may consider mixing it with atropine instead of glycopyrrolate to get the anti-emetic effects of the atropine.* ## Footnote Slide 16

Question 53

# True or False Giving a NMDB that does not have to be reversed is another way to prevent PONV

Answer 53

True M - *you could obviously give neuromuscular blockers that don't need to be reversed like succinylcholine if long acting muscle relaxation is not needed. And you can get away with just enough to get the breathing tube in for the procedure and the surgeon doesn't need muscle relaxation or doesn't want it for their case.* ## Footnote Slide 16

Question 54

# Matching Question

Answer 54

0 risk factors → C. 10% 1 risk factor → D. 20% 2 risk factors → E. 39% 3 risk factors → A. 60% 4 risk factors → B. 79% ## Footnote Slide 17

Question 55

Which of the following is a key finding from the development of the Apfel score related to anesthesia? A) General anesthesia was identified as a protective factor. B) Regional anesthesia was identified as a culprit for PONV. C) General anesthesia was identified as a culprit for PONV. D) Local anesthesia significantly increases the risk of PONV.

Answer 55

C) General anesthesia was identified as a culprit for PONV. ## Footnote Slide 17

Question 56

Which of the following procedures are identified as high risk for PONV according to the Apfel score? (Select 4 that apply) A) ENT surgery B) Dental surgery C) Breast surgery D) Cardiac surgery E) Laparoscopic Bilateral Tubal Ligation F) Neurosurgery

Answer 56

A) ENT surgery B) Dental surgery C) Breast surgery E) Laparoscopic Bilateral Tubal Ligation ## Footnote Slide 17

Question 57

Which of the following is NOT a predictor of PONV according to the Apfel score? A) Female gender B) Smoking C) Use of postoperative opioids D) History of PONV or motion sickness

Answer 57

B) Smoking Mordecai: *and non-smokers being higher risk than smokers.* ## Footnote Slide 17

Question 58

At what number of risk factors, according to the Apfel score, is prophylaxis for PONV recommended? A) 0 risk factors B) 1 risk factor C) 2 risk factors D) 3 risk factors E) 4 risk factors

Answer 58

C) 2 risk factors ## Footnote Slide 17

Question 59

# Matching

Answer 59

***Low risk of PONV, Low risk** of medical sequela* → (B) Reduce baseline risk with **NO prophylaxis with 5HT3 antagonist** for rescue ***Low risk of PONV, High risk** of medical sequela *→ (C) Reduce baseline risk with **5HT3 antagonist for prophylaxis, rescue using different class** ***Moderate risk of PONV,** Any risk of medical sequela* → (D) Reduce baseline risk with **5HT3 antagonist + steroid for prophylaxis, rescue using different class** ***High risk of PONV,** Any risk of medical sequela* → (A) Reduce baseline risk with **5HT3 antagonist + steroid + propofol TIVA + scopolamine for prophylaxis, rescue using different class** ## Footnote Slide 18

Question 60

When managing PONV, which of the following drugs can be used as rescue therapy from a different drug class if initial prophylaxis was with a 5HT3 antagonist? (Select 3 that apply) A) Phenothiazine B) Dexamethasone C) Antihistamine D) Metoclopramide E) Ondansetron

Answer 60

A) Phenothiazine C) Antihistamine D) Metoclopramide Mordecai: *the tail end of things you would come at it targeting a different receptor using a different class of drug* ## Footnote Slide 18

Question 61

What is P6 stimulation, and how is it used in the management of postoperative nausea and vomiting (PONV)? A) P6 stimulation involves applying pressure or acupuncture to a specific point on the inner wrist. B) P6 stimulation is a pharmacological intervention for PONV. C) P6 stimulation targets a point on the outer wrist. D) P6 stimulation is located approximately 5 finger widths above the elbow. E) P6 stimulation requires the use of antiemetic medications for its effect.

Answer 61

A) P6 stimulation involves applying pressure or acupuncture to a specific point on the inner wrist. *Radial compression* ## Footnote Slide 20

Question 62

How is P6 stimulation thought to treat postoperative nausea and vomiting (PONV)? A) By inhibiting gastric motility through vagal stimulation. B) By promoting the release of serotonin in the central nervous system. C) Through hypophyseal secretion of β-endorphins, leading to inhibition of the chemoreceptor trigger zone (CTZ). D) By stimulating dopamine release in the brainstem.

Answer 62

C) Through hypophyseal secretion of β-endorphins, leading to inhibition of the chemoreceptor trigger zone (CTZ). Mordecai: *basically the idea is that it decreases gastric acid secretion and can reduce some nausea.* ## Footnote Slide 20

Question 63

# True or False P6 manipulation is only effective for inhibiting nausea but has no effect on vomiting

Answer 63

TRUE Mordecai: ***Show probably inhibits nausea more than vomiting**, but studies show that it's time limited and may only be mildly effective.* ## Footnote Slide 20

Question 64

The __ receptor antagonists are anti-emetic. They also can be used as __ drugs and __ drugs. A) Serotonin, analgesic, antihypertensive B) Dopamine, antipsychotic, neuroleptic C) GABA, sedative, antianxiety D) Histamine, antihistamine, anti-inflammatory

Answer 64

B) Dopamine, antipsychotic, neuroleptic The **Dopamine** receptor antagonists are anti-emetic. They also can be used as **antipsychotic** drugs and **neuroleptic** drugs. | Anti-dopaminergics ## Footnote Slide 21

Question 65

Which of the following are subtypes of anti-dopaminergic drugs that are used to treat postoperative nausea and vomiting (PONV)? (Select 2 that apply) A) Butyrophenones B) Serotonin antagonists C) Phenothiazines D) Antihistamines E) Benzodiazepines

Answer 65

A) Butyrophenones C) Phenothiazines ## Footnote Slide 21

Question 66

Which of the following are common side effects of dopamine receptor antagonists? (Select 2 that apply) A) Drowsiness/sedation B) Hypertension C) Extrapyramidal signs and symptoms D) Hyperactivity E) Tachycardia

Answer 66

A) Drowsiness/sedation C) Extrapyramidal signs and symptoms ## Footnote Slide 21

Question 67

Which of the following drugs are classified as butyrophenones? (Select 2 that apply) A) Haloperidol B) Ondansetron C) Droperidol D) Metoclopramide E) Promethazine

Answer 67

A) Haloperidol C) Droperidol Memory trick: *Halo and Dro for Butyro!* ## Footnote Slide 22

Question 68

What black box warning exists for Droperidol? A) Respiratory depression and coma B) Torsades de Pointes and sudden death C) Seizures and liver toxicity D) Hypertension and bradycardia

Answer 68

B) Torsades de Pointes and sudden death ## Footnote Slide 22

Question 69

More than __ mg of Droperidol should never be given. A) 1 mg B) 0.625 mg C) 2 mg D) 5 mg

Answer 69

**B) 0.625mg** Mordecai: *initially when Droperidol came out, it was dosed at 1.25 to 2 1/2 milligrams, but they found that it can be effective at lower doses and really reduce the risks with the smaller doses.* ## Footnote Slide 22

Question 70

Droperidol is as effective as ___ for the treatment of PONV. A) Metoclopramide 10 mg B) Ondansetron 4 mg C) Dexamethasone 8 mg D) Scopolamine 1.5 mg

Answer 70

B) Ondansetron 4mg ## Footnote Slide 22

Question 71

Droperidol also has effects as a ________ resulting in hypotension. A) potent β blocker B) weak α blocker C) calcium channel blocker D) potassium channel blocker

Answer 71

B) weak α blocker ## Footnote Slide 22

Question 72

Which of the following statements about Haloperidol is true? (Select 2 that apply) A) Haloperidol is commonly approved for the treatment of PONV. B) Haloperidol is not approved for intravenous (IV) use. C) Haloperidol is not approved for PONV. D) Haloperidol is a common antiemetic drug.

Answer 72

B) Haloperidol is not approved for intravenous (IV) use. C) Haloperidol is not approved for PONV. ## Footnote Slide 22

Question 73

When combined with droperidol, __ mg of metoclopramide is more __. A) 5 mg, effective B) 10 mg, effective C) 15 mg, potent D) 20 mg, toxic

Answer 73

B) 10 mg, effective ## Footnote Slide 22

Question 74

Which of the following drugs are classified as phenothiazines? (Select 3 that apply) A) Prochlorperazine B) Chlorpromazine C) Ondansetron D) Promethazine E) Metoclopramide

Answer 74

A) Prochlorperazine B) Chlorpromazine D) Promethazine ## Footnote Slide 23

Question 75

What black box warnings exist for Promethazine? (Select 2 that apply) A) Hepatotoxicity B) Tissue damage C) Respiratory arrest in children under 2 years old D) QT prolongation E) Severe bradycardia

Answer 75

B) Tissue damage C) Respiratory arrest in children under 2 years old ## Footnote Slide 23

Question 76

In addition to dopamine receptors, Promethazine also antagonize which of the following receptors? (Select 3 that apply) A) Alpha-adrenergic receptors B) Histamine receptors C) Muscarinic cholinergic receptors D) Beta-adrenergic receptors E) Serotonin receptors

Answer 76

A) Alpha-adrenergic receptors B) Histamine receptors C) Muscarinic cholinergic receptors ## Footnote Slide 23

Question 77

Which of the following are known side effects of Promethazine? (Select 3 that apply) A) Sedation B) Hypertension C) Hypotension D) Extrapyramidal symptoms (EPS) E) Tachycardia

Answer 77

A) Sedation C) Hypotension D) Extrapyramidal symptoms (EPS) ## Footnote Slide 23

Question 78

The typical dose range for Promethazine is __ mg. A) 5-10 mg B) 12.5-25 mg C) 25-50 mg D) 50-100 mg

Answer 78

B) 12.5-25 mg ## Footnote Slide 23

Question 79

How do 5HT3 antagonists work in the treatment of nausea and vomiting? A) They block dopamine receptors in the brain. B) They antagonize serotonin receptors on the vagal nerve and chemoreceptor trigger zone (CTZ). C) They inhibit histamine release in the GI tract. D) They increase gastric motility by stimulating cholinergic receptors.

Answer 79

B) They **antagonize serotonin receptors** on the vagal nerve and chemoreceptor trigger zone (CTZ). ## Footnote Slide 24

Question 80

Which of the following are common side effects of 5HT3 antagonists? (Select 3 that apply) A) Headache B) Diarrhea C) Constipation D) Mild elevation in liver enzymes E) Sedation

Answer 80

A) Headache C) Constipation D) Mild elevation in liver enzymesLiver enzymes ## Footnote Slide 24

Question 81

When should Ondansetron 4 mg be administered to prevent PONV? A) At the start of surgery B) 4 mg within 15-20 minutes of the end of surgery C) 4 mg immediately after induction of anesthesia D) 4 mg 1 hour before surgery

Answer 81

B) 4mg within 15 - 20 min of surgery end. *unclear on 4mg vs. 8mg* ## Footnote Slide 24

Question 82

Which of the following are 5HT3 antagonists used for the treatment of PONV? (Select 4 that apply) A) Dolasetron (Anzemet) B) Granisetron (Kytril) C) Ondansetron (Zofran) D) Palonosetron E) Metoclopramide F) Haldol G) Promethazine

Answer 82

A) Dolasetron (Anzemet) B) Granisetron (Kytril) **C) Ondansetron (Zofran)** D) Palonosetron Memory Trick: *TRON on anti-5HT3s* ## Footnote Slide 24

Question 83

Which anticholinergic drug is commonly given for PONV prophylaxis, and what is the recommended dosing? A) Glycopyrrolate, 0.2 mg IV every 4-6 hours B) Atropine, 1 mg transdermal patch; leave in place 24 hours C) Scopolamine, 1.5 mg transdermal patch; leave in place 48-72 hours D) Ipratropium, 1.5 mg transdermal patch; leave in place 48 hours

Answer 83

C) Scopolamine, 1.5 mg transdermal patch; leave in place 48-72 hours *Blocks acetylcholine* ## Footnote Slide 25

Question 84

Which of the following are common side effects of Scopolamine? (Select 3 that apply) A) Drowsiness B) Dry mouth C) Tachycardia D) Dizziness E) Diarrhea

Answer 84

A) Drowsiness B) Dry mouth D) Dizziness *Care with handling* ## Footnote Slide 25

Question 85

Which of the following is *typical application site* for a Scopolamine transdermal patch? A) Behind the ear B) On the upper chest C) On the upper outer arm D) On the lower abdomen E) On the hip

Answer 85

**A) Behind the ear** But can be placed on: - upper chest - upper outer arm - lower abdomen - the hip - inner malleous of the ankle Mordecai: *you want to place it in an area where the skin is very thin and vascular so that it can absorb* ## Footnote Slide 25

Question 86

With the PONV prophylaxis dose of Dexamethasone, how does 4 mg compare to 8 mg? A) 4 mg is less effective than 8 mg B) 4 mg is as effective as 8 mg C) 4 mg is more effective than 8 mg D) 4 mg should be used only in pediatric patients

Answer 86

B) 4 mg is as effective as 8 mg Mordecai: *generally given right after induction and it really will significantly reduce airway swelling also.* ## Footnote Slide 26

Question 87

Which of the following is true regarding Dexamethasone ? A) Dexamethasone decreases postoperative pain and edema. B) Dexamethasone is effective as a rescue medication for PONV. C) Dexamethasone has significant adverse side effects.

Answer 87

A) Dexamethasone **decreases postoperative pain and edema.** *Anti-inflammatory reaction* *** No adverse side effects** Glycemic effect? *it could technically increase the blood sugars in our diabetic patients. So a lot of times we'll avoid it in our brittle diabetics* *** Not useful for rescue** ## Footnote Slide 26

Question 88

Which of the following statements are true about Metoclopramide and its role in treating PONV? (Select 3 that apply) A) It increases LES (lower esophageal sphincter) tone. B) It increases GI motility. C) It is more efficacious than Droperidol. D) It is less efficacious than Droperidol. E) It decreases LES tone and gastric motility.

Answer 88

A) It increases LES (lower esophageal sphincter) tone. B) It increases GI motility. D) It is less efficacious than Droperidol. ## Footnote Slide 27

Question 89

Which of the following are known side effects of Metoclopramide? (Select 2 that apply) A) Sedation B) Restlessness C) Extrapyramidal symptoms (EPS) D) Tachycardia E) Respiratory depression

Answer 89

B) Restlessness C) Extrapyramidal symptoms (EPS) ## Footnote Slide 27

Question 90

The recommended IV dose of Metoclopramide for PONV is __ mg. A) 5-10 mg B) 10-20 mg C) 20-30 mg D) 25-50 mg

Answer 90

**B) 10-20 mg** *Short ½ life* ## Footnote Slide 27

Question 91

Aprepitant (Emend) is a NK-1 antagonist that antagonizes __ in the emetic center. Depress neural activity of the __. May also interfere with afferent messages from __ cells. A) Serotonin, CTZ, epithelial B) Dopamine, hippocampus, enterochromaffin C) Substance P, nucleus tractus solitarius, enterochromaffin D) Histamine, brainstem, parietal

Answer 91

Aprepitant is a NK-1 antagonist that antagonizes **Substance P** in the emetic center. Depresses neural activity of the **nucleus tractus solitarius**. May also interfere with afferent messages from **enterochromaffin** cells. ## Footnote Slide 28

Question 92

# True or False Aprepitant (Emend) has lesser anti-vomiting effects than anti-nausea effects.

Answer 92

False *Aprepitant has **greater anti-vomiting effects** than anti-nausea effects.* ## Footnote Slide 28

Question 93

What is the recommended dose of Aprepitant (Emend) for PONV prophylaxis? A) 10 mg or 25 mg B) 20 mg or 50 mg C) 40 mg or 125 mg D) 200 mg or 300 mg

Answer 93

C) 40mg or 125mg ## Footnote Slide 28

Question 94

When should Aprepitant (Emend) be administered for PONV prophylaxis? A) 30 minutes before surgery B) Immediately after surgery C) 2-3 hours prior to induction D) During postoperative recovery

Answer 94

C) 2-3 hours prior to induction ## Footnote Slide 28

Question 95

How does Propofol prevent or treat PONV? (Select 2 that apply) A) It blocks dopamine receptors in the chemoreceptor trigger zone (CTZ). B) It blocks serotonin release in subhypnotic doses. C) It inhibits acetylcholine release in the gut. D) It may inhibit the chemoreceptor trigger zone (CTZ). E) It enhances gastric motility.

Answer 95

B) It blocks serotonin release in subhypnotic doses. D) It may inhibit the chemoreceptor trigger zone (CTZ). ## Footnote Slide 29

Question 96

What is the subhypnotic/TIVA dose of Propofol used for PONV prophylaxis? A) 10 mcg/kg/min B) 16.7 mcg/kg/min C) 25 mcg/kg/min D) 50 mcg/kg/min

Answer 96

B) 16.7 mcg/kg/min ## Footnote Slide 29

Question 97

Which drug is commonly given alongside Propofol to counteract bradycardia? A) Atropine B) Glycopyrrolate C) Metoprolol D) Epinephrine

Answer 97

B) Glycopyrrolate ## Footnote Slide 29

Question 98

Which of the following is NOT considered an effective method for reducing nausea? (Select 3 that apply) A) Isopropyl alcohol aromatherapy B) Adequate pre-hydration (10-30 mL/kg) C) Chewing gum D) Peppermint aromatherapy E) Carbohydrate loading F) Ginger

Answer 98

**D) Peppermint aromatherapy** M: *Research doesn't really show that peppermint is that effective, but there are some people that swear by peppermint* **E) Carbohydrate loading** M: *but research varies and the idea is that stabilizing blood glucose can reduce nausea.* **F) Ginger** *No significant reduction* ## Footnote Slide 30

Question 99

Which of the following should be considered as potential causes of nausea or other complications in a postoperative patient? (Select 5 that apply) A) Elevated intracranial pressure (ICP) B) Hypoxemia C) Gastric bleeding D) Hypotension E) Hypoglycemia F) Hypertension

Answer 99

**A) Elevated intracranial pressure (ICP)** **B) Hypoxemia** M: *when the oxygen levels are low, that can trigger nausea* **C) Gastric bleeding** M: *because of gastric distention that's going to occur with that* **D) Hypotension** M: *may be experiencing nausea due to hypotension and a lot of times in our pregnant women...if you're taking them back for a C section and you do a spinal and their SVR drops, they're going to have significant nausea as soon as that spinal.* **E) Hypoglycemia** M: *those patients that are cold, clammy, shaky with low blood sugar, they're more likely to experience nausea as well.* ## Footnote Slide 31

Question 100

# Case Study Question A 14-year-old girl with a history of motion sickness is scheduled for adenotonsillectomy. She has had multiple episodes of postoperative nausea and vomiting (PONV) despite receiving intraoperative, prophylactic antiemetic therapy during previous surgeries. After her last surgery, she was hospitalized for dehydration due to refractory postoperative emesis. What strategies could be employed to help prevent PONV in this patient? (Select 7 that apply) A) Anxiolysis with benzodiazepines (BZD) B) Use of Propofol TIVA and avoiding volatile agents C) Minimal opioid use, supplemented with acetaminophen and nerve blocks D) Avoidance of liberal IV fluids E) Include steroids during induction and 5HT3 antagonists F) Use of nitrous oxide as an anesthetic agent G) Gentle, easy movements with no forced ambulation H) Avoid the use of NMBDs that require neostigmine reversal I) Aggressive treatment with multiple antiemetic classes if necessary

Answer 100

A) Anxiolysis with **benzodiazepines (BZD)** B) Use of **Propofol TIVA** and avoiding volatile agents C) **Minimal opioid use**, supplemented with acetaminophen and nerve blocks E) Include **steroids** during induction and **5HT3 antagonists** G) Gentle, easy movements with **no forced ambulation** H) **Avoid** the use of NMBDs that require **neostigmine reversal** I) Aggressive treatment with **multiple antiemetic classes** if necessary ## Footnote Slide 33