Week 2 PONV (everything) Flashcards by Amanda D

2 intraop factors that influence PONV

type of surgery and duration of surgery

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what 3 surgeries have the high incidence of PONV

cholecystectomy, gynecological and lap surgeries

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how would increasing surgical time (duration) by 30 minutes effect the risk for PONV?

increasing surgical duration increases risk of PONV by 60%

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what inhaled anesthetic increases the risk for PONV?

Nitrous Oxide:

avoiding NO significantly decreases vomiting in Lap procedures and PONV

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Nitrous oxide’s association with PONV is suggested to be due to what 3 factors?

Simulation of sympathetic system with catecholamine release

Middle ear pressure changes stimulating the vestibular system

Increased abdominal distension. This is from the exchange of Nitrous oxide and nitrogen in gas introduced into GI tract by mask ventilation

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effect of Ether and Cyclopropane on PONV

Ether and Cyclopropane cause higher PONV d/t increase in endogenous catecholamines

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effect of volatile gases on PONV in the early stage (0-2hr) vs delayed stage (2-24hr) of surgery

Volatiles gases were primary cause of early PONV (0-2 hours)

Volatile gases have no impact on delayed PONV (2-24 hours)

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which volatile anesthetics are asociated with a lower risk for PONV

Sevoflurane, Enflurane, Desflurane, and Halothane

all but Ether and Cyclopropane: Iso was not mentioned

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effect of volatile gases on PONV depends on what?

the effect is dose dependent

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Etomidates effect on PONV

Continuous infusion markedly increases post-op emesis

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why does ketamine increase the risk for PONV

related to release of endogenous catecholamine release:

ketamine causes hallucinations, vivid dreams and increased risk for PONV

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Of Barbiturates, Nitrous Oxide and Ketamine which has a higher risk for PONV

Ketamine

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how does Propofol effect PONV

reduces the risk

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Nitrous-Opioid-Relaxant technique: how does it effect PONV

increases the incident of PONV d/t directly stimulating the CTZ

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MOA of opioids contribution to increased risk for PONV.

Emesis caused by stimulation of opioid receptors in the CTZ.
Using intraoperative opioids shows a weak contribution to PONV.
DOSE DEPENDENT EFFECT

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Do neuromuscular reversal agents increase risk for PONV?

it is unknown/uncertain

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regional vs general anesthesia: what is the risk for PONV

GA is 9x more likely to cause PONV compared to Regional

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do central neuraxial blocks or peripheral blocks cause a greater risk for emesis?

central neuraxial blocks

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why is Emesis with central neuraxial blocks greater than with peripheral blocks

d/t SNS block contributing to postural hypotension induced N/V

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what would decrease the risk for nausea with epidurals

nausea is less with lipid soluble opioids such as fentanyl and sufentanil

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why does using lipid soluble opioids in epidurals decrease the risk for nausea

d/t less rostral spread from lumbar epidural injection site to CTZ and vomiting center than the less lipid soluble such as morphine

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what type of pain is more commonly related to PONV

visceral or pelvic pain

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how does movement or transport effect PONV

Sudden motion, changes in position, and/or transport from PACU to patient floor can precipitate n/v after receiving opioids

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during what point in the surgical process would we use Non steroidals and why do we use them

used perioperatively to reduce need for opioids

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what is no longer recommended for PONV prevention

supplemental O2

Genes/receptors regarded as r/t PONV or opioid induced N/V: | 8

5-HT3 D - Dopamine type 2 A - Alpha-2 adrenoceptor M - Muscarinic type-3 C - Catechol-o-methyl transferase A - Adenosine triphosphate (binding cassette subfamily B member) U - Uridine 5’-diphospho-glucuronosyltransferae C - Cytochrome P450 superfamily enzyme ***5 DAM CAUC (s)**

5 Primary Afferent Pathways involved in vomiting stimulation:

1. Chemoreceptor Trigger Zone (CTZ) 2. Vagal mucosal pathway in the GI system 3. Neuronal Pathways from the Vestibular system (Inner ear) 4. Reflex afferent pathways from the cerebral cortex 5. Midbrain afferents

Stimulation of the afferent pathways stimulating vomiting can be activated by four receptor types:

1. Cholinergic (muscarinic) 2. Dopaminergic 3. Histaminergic 4. serotonergic

Vomiting center is located within:

the reticular formation of the brainstem Flood says medulla oblongata and consists of nucleus of the tractus solitaires and parts of the reticular formation

The vomiting center received afferent inputs from

the 5 afferent pathways

Efferent signals are directed to the following nerves:

Flood states V, Vii, IX, X, Xii ``` Glossopharyngeal Hypoglossal Trigeminal Accessory Spinal segmental ```

the gut, oropharynx, movement, pain, hypoxemia, and hypotension can all do what

stimulate the vomiting center

CTZ is located

Outside the BBB

What has contact with CSF and allows substances in blood and CSF to interact.

CTZ

Toxins and/or drugs in the blood can stimulate the CTZ causing ____ . This stimulation may send :

Cause: N/V Send: emetogenic triggers to the vomiting center activating the vomiting reflex

emetogenic triggers to the vomiting center activating

the vomiting reflex

Vomiting is associated with marked vagal and sympathetic activity causing:

Sweating Bradycardia Pallor

PONV is influenced by multiple factors that are r/t:

Patient Surgery Anesthesia

PONV Risk Factors:

- Women - Previous history motion sickness or PONV from previous surgeries - Nonsmokers - < 50 years of age is a significant factor

strongest predictive factor for PONV

Women>men flood: because of the effects of progesterone/estrogen on the CTZ or Vomiting center

patient/factor that decreases PONV due to gradual desensitization of the CTZ

Smokers

recent studies demonstrate that this is NOT a factor in pt PONV factors:

BMI is not a factor

Factors of Delayed Gastric Emptying:

``` MD Hypothyroidism Pregnancy Increased ICP Swallowing blood Full stomach ```

Corticosteroids | Methylprednisolone what is this effective for

late PONV prevention

haloperidol antiemetic dose and side effects

<2mg reduces the risk of side effects and QT prolongation. Not FDA approved.

droperidol - receptors

relatively selective D2 receptor antagonist

why was droperidol stopped in 2001

black box warning related to CV events- QT prolongation

what did the recent meta analysis demonstrate for droperidol

low doses <1mg or 15mcg/kg IV has significant antiemetic efficacy with low risk of adverse reactions

perphenazine used for

to treat schizophrenia and n/v

chlorpromazine works on which receptor

d2 receptor antagonist at CTZ

what can chlorpromazine cause

severe sedation

what does chlorpromazine treat

``` schizophrenia mental illness behavioral disorders tetanus blood disorders such as porphyria severe n/v ```

Propofol- other than sedation what can we use propofol for

Used in TIVA can reduce baseline risk of PONV

Alpha-2-agonists- has what two effects

Has direct antiemetic effect along with opioid sparing effect

Clonidine and Dexmedetomidine- how long do their anti nausea effects last?

demonstrated a significant but weak and short lived antinausea effect (meta-analysis)

IV Fluids are these effective for PONV

Effective for reducing the baseline risk for PONV.

midazolam how much do we give and when do we give it

2mg 30 min before end of surgery is as effective as zofran 4mg 2mg 30 min before end of surgery is more effective against PONV than 35mcg/kg premedication

gabapentin- how much do we give 2 hrs prior to surgery

600mg 2 hrs prior to surgery effectively decreases PONV

if we want to gabapentin 1 hour before surgery how much do we give adding "this med" to gabapentin is better for PONV than either drug alone

800mg PO -as effective as dexamethasone 9mg IV *yet the combination of gabapentin and dexmethasone is better than either drug given alone*

mirtazepine (remeron) - type and class

antidepressant | specific serotonergic and noradrenergic antidepressant

Strategies that do not work for antiemetic drugs

``` Music therapy Isopropyl alcohol inhalation Intraoperative gastric decompression The proton pump inhibitor esomeprazole (Nexium) Ginger root Nicotine patch to nonsmokers Cannabinoids ```

Sister Anna Has Double Nausea

receptor antagonism serotonin (5-hydroxytryptamine subtype 3 ) antagonist anticholinergics/antimuscarinics (M) Histamine H1 antagonist Dopamine (D2) antagonist Neurokinin 1 antagonist

anticholinergics antimuscarinics drug example

scopolamine

histamine H1 antagonist example

``` promethazine perphenazine dimenhydrinate diphenhydramine meclizine chlorpromazine ```

dopamine d2 antagonist examples

``` domperidone chlorpromazine metoclopramide droperidol haloperidol ```

neurokinin 1 antagonist example

aprepirant cospitant rolapitant

serotonin (5-hydroxytryptamine subtype 3 ) antagonist *they all have the same ending except for one!

``` ondansetron granisetron dolasetron ramosetron palonosetron tropisetron corticosteroid ```

Shaikh, S., Nagarekha, D., Hegade, G., & Marutheesh, M. (2016). Postoperative nausea and vomiting: A simple yet complex problem. Anesthesia Essays Resources, 10(3). 388-396.

...

What type of drug is ondansetron and dolasertron?

5-HT3

Zofran dose should not exceed what mg according to the FDA and for what reason?

FDA recommends that a single dose should not exceed 16 mg d/t risk of QT prolongation.

What med was banned by the FDA in 2010 in use for chemotherapy-induced N/V in adults and children d/t concerns of QT prolongation and torsade's de pointes?

Dolasetron

of the drugs in the group 5-HT3, which drug is the most used by anesthesia (and perhaps in the hospital)

Zofran

How do Anticholinergic/ Antimuscarinic induce antiemetic effects?

Blocks muscarinic receptors in the cerebral cortex and pons.

How does Transdermal Scopolamine work?

Competitive inhibitor at postganglionic muscarinic receptors in the PNS and acts directly on the CNS by antagonizing cholinergic transmission in the vestibular nuclei.

How do histamine receptor antagonist work?

Blocks acetylcholine receptors in the vestibular apparatus and histamine receptors in the nucleus tractus solitaries.

What are three examples of Histamine receptor antagonists?

Dimenhydrinate (Dramamine) Meclizine: Has longer during of PONV effect than ondansetron Promethazine

What drug is a Dopamine antagonist?

Reglan

What all receptors does Reglan block? (3 answers)

Metoclopramide: Strong D2-receptor antagonist and blocks H1 and 5-HT3 receptors as well.

True or false: | reglan increases duodenal peristalsis?

True

What drug matches the description below: Enhances 5-HT4 receptors and upper GI tract motility to promote gastric emptying without affecting gastric, biliary, and pancreatic secretion.

Reglan (dopamine - antagonist)

Is Reglan known as a strong or weak antiemetic?

weak antiemetic, it works mostly to increase gastric emptying. (think of it's antiemetic abilities as a happy side effect)

Will you use Reglan with opioid use or not?

You can use reglan with opioid use, because with opioids you have delayed emptying of the stomach and by using reglan you Increases GE sphincter tone an decreases pyloric sphincter tone to prevent delayed emptying associated with opioid use.

What are Neurokinin-1 Receptor Antagonists?

New group of drugs used for PONV thought to prevent both acute and delayed emesis.

Where does Neurokinin- 1 receptor antagonist work at physiologically?

Act mainly at nucleus tractus solitaries and areas of reticular formation blocking NK-1 receptors.

Is Neurokinin-1 Receptor Antagonists more effective at inhibiting nausea or emesis?

Emesis

Aprepitant is a Neurokinin-1 Receptor Antagonists, what is the name of the PO version and the IV version?

Emend [PO], Cinvanti [IV]

What is the half life of Aprepitant Emend [PO], Cinvanti [IV] ?

40 hours

What drug is more effective than zofran for preventing vomiting at 24 and 48 hour after surgery and in reducing nausea severity in the first 48 hours after surgery?

Aprepitant Emend [PO], Cinvanti [IV]

Two meds listed in the power point that are Neurokinin-1 Receptor Antagonists, not approved for use yet? (who knows what he will test over lol)

Cospitant and Rolapitant