Ponv

Post Operative Nausea & Vomiting John Zois 2005

PONV Why is it Important? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Physiology of PONV ,[object Object],[object Object],[object Object],[object Object],[object Object]

Consensus Guidelines ,[object Object],[object Object]

Risk Stratification ,[object Object],[object Object],[object Object],[object Object]

Risk Stratification ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Risk Stratification ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Risk Stratification ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Risk Stratification ,[object Object],[object Object],[object Object],[object Object],[object Object]

Quick Risk Factor Chart ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Risk Stratification High Risk of PONV pts Aggressive prophylaxis + treatment. Expensive but becomes cost-effective when the issues of patients satisfaction and avoidance of unplanned admission are considered. Multi-modal therapy widely accepted as providing the best results

Treatment Modalities Some of the treatments used around the world include: metoclopramide domperidone droperidol Dopamine antagonists dexamethasone Corticosteroid scopolamine (L-hyoscine) Anti-cholinergic promethazine Anti-histamine ondansetron , tropiseron, granisetron 5HT3-receptor antagonist

Pharmacology ,[object Object],ONDANSETRON Four types of serotonergic (5-HT) receptors (5-HT1-4). 5-HT1 receptors are subdivided further (5-HT1A etc). Ondansetron is a highly selective antagonist at 5-HT3 receptors; it has an affinity 250-1000 times greater for the 5-HT3 receptor than for any other receptor. The drug antagonises 5-HT3 receptors both centrally and peripherally. Emetogenic stimuli result in the release of 5-HT in the small intestine and initiate a vomiting reflex (via vagal afferents, via 5-HT3 receptors). Thus, Ondansetron blocks the initiation of this reflex. Drug of choice in children. Dose =350mcg/kg

Pharmacology ,[object Object],Recent evidence has shown that dexamethasone is effective prophylaxis for PONV, at least as effective as droperidol and the serotonin antagonists when used as a single agent. It is orders of magnitude cheaper than the 5HT3 anatagonists. Dose required for this effect is very low (eg 2.5-5 mg IV and as such it causes no significant side effects) given early during the anesthetic. However has no role in the treament of established PONV, thus serotonin antagonists remain the mainstay in such circumstances.

Pharmacology ,[object Object],For many years, droperidol (in very small doses) was very popular in any strategy against PONV. Droperidol is very effective in small doses (0.625-1.25mg) for the prevention and treatment of PONV and was once considered almost as a gold standard when it came to comparing the efficacy of other medications. Being very inexpensive also further added to its popularity. Unfortunatey its use has declined after its association with rare fatal arrythmias (although at higher doses)

Pharmacology ,[object Object],Used in the prophylaxis of motion sickness and as an antispasmodic. Competitive antagonism of acetylcholine at muscarinic receptors. Hyoscine has been shown to reduce postoperative nausea and vomiting related to opiods. It also decreases muscle tone and secretions in the gut, which may contribute to its antiemetic properties. Hyoscine

Pharmacology ,[object Object],Antagonism of peripheral dopaminergic D2 receptors. Results in increased gastrointestinal motility and tone. Although metoclopramide has prokinetic effects that enhance gastric and upper intestinal motility, it is no more effective as an antiemetic than a placebo according to some trials.

Combination Therapy ,[object Object]

Non Pharmacological Therapy ,[object Object],[object Object],[object Object]

In Summary.. ,[object Object],[object Object],[object Object]

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Ponv

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