Title: EvidenceBased Practice for Management of PONVPDNV: The ASPAN Guidelines
1Evidence-Based Practice for Management of
PONV/PDNV The ASPAN Guidelines
- Pamela E. Windle, MS, RN, CNA, BC, CPAN, CAPA
- ASPAN Immediate Past President 2007-2008
- Houston, Texas
2PONV History
- 1934 PONV was the most feared complication with
general anesthesia (ether inhalation agents) - 1950s Chemoreceptor Trigger Zone (CTZ) started
- Is it nausea, retching, or vomiting?
Raeder J. Int Anesthesiol Clin. 200341(4) 1-12.
3Definitions
- Nausea subjective experience with the
inclination to vomit (may or may not be
associated together) - Objective experience
- Retching rhythmic action of respiratory muscles
preceding vomiting - Vomiting forceful expulsion of GI contents
through the mouth (emesis)
Board T, Board R. AORN. 2006 83(1) 209-219.
4What nurses know
- PONV is a common complaint post-operatively,
occurring in up to 80 of patients not caused by
a single event, and 25 continue to complain
about PONV within 24 hrs of surgery1-3 - PDNV has not been followed as closely as PONV.
Reports of PDNV range from 29 -311 and some will
experience up to 5 days postop3 -
1Carroll NV, et al. Anaesth Analg.199580(5)903-9
09. 2Pfisterer M, et al. Ambul Surg.
20019(1)13-18. 3Odom-Forren J and Moser DK.
Journal of Ambul Surg. 20051299-105.
5Incidence of PONV/PDNV
- Overall range 2530
- High-risk patients 7080
- Outpatient range 2080, depending on the
patient population
Kovac AL. Drugs. 200059213-243. Natof HE, et
al. In Wetchler BV, ed. Anesthesia for
Ambulatory Surgery. 2nd ed. 1991437-474. Carroll
NV, et al. Anesth Analg. 199580903-909. Gan TJ,
et al. Anesth Analg. 2002941199-2000. Gan TJ.
JAMA. 20022871233-1236. Leslie JB and Bash D.
Poster presented at NYSSA 57th Postgraduate
Assembly December 13, 2003 NYC, NY. Gan TJ, et
al. Anesth Analg. 20039762-71. Chung F, et al.
Eur J Anaesthesiol. 199916669-677. Hirayama T,
et al. Yakugaku Zasshi. 2001121179-185.
6Clinical Consequences of PONV
- Patient discomfort (mild to severe)
- Wound dehiscence
- Aspiration of gastric content
- Electrolyte imbalance and dehydration
- Interruption in or delay of oral drug therapy,
fluid intake, or eating - Hematoma formation beneath skin flaps
- Mallory Weis tear, esophageal rupture, pneumonia
- Damage to delicate surgery such as eye, plastic
vascular - Delayed stay in Phase I II PACU
- Unplanned admission
Kovac AL. Drugs. 2000 59(2)213-243.
7Childrens Risk
- Studies are often limited to data on vomiting and
not nausea - No gender difference
- Surgery related risk TA, strabismus, hernia,
penile surgery (orchipexy) - Risk increases with age
- 2 year old
- Decreases at puberty
8 Vomiting Center
- Acts upon sensory input
- Activates efferent motor pathways
- Receptors
- Cholinergic
- Histamine
- Opioid
- NK1
9ASA 2003 Consensus Guidelines
- Identify primary risk factors
- Reduce baseline risks
- Identify optimal approach
- Identify optimal timing
- Identify most effective mono- and combo- therapies
Gan TJ, et al. Anesth Anal. 2003 9762-71.
10PONV/PDNV Consensus ConferenceMarch 24-26,
2006ASPAN/ASA/AANA Expert Panel
- 16 multi-disciplinary, multi-specialty
experts - ASPAN experts
- PharmD
- 2 ASA representatives
- 2 AANA representatives
- DNP student
Pharmacists
11Guidelines Are...
- NOT intended as standards or absolute
requirements - ARE to be adopted, modified, or rejected
according to specific clinical needs or
restraints
12Goals/Specific Aims
- Critique synthesize the evidence regarding the
prevention /or management of PONV/PDNV in the
adult population - Develop multi-disciplinary, multi-modal,
evidence-based recommendations regarding the
prevention /or management of PONV/PDNV - Identify areas of needed research
13PONV Terms
- Nausea /or vomiting that occurs within the first
24-hour period postoperatively following surgery
14PDNV Terms
- Nausea /or vomiting that occurs after discharge
from the health care facility following surgery
15 PONV/PDNV Guidelines 2006
- Available at
- www.aspan.org
- Endorsed by
- AANA
- ASA
16What are the Risk Factors?
- Anesthetic-Related Risk
- Factors
- Intraoperative and postoperative opioids
- General anesthesia
- Use of volatile anesthetics within 02 hours
- Use of nitrous oxide
- Surgical Risk Factors
- Longer duration of surgery
- Increases every 30 minutes
- Type of surgery
- Plastic
- Laparoscopic/laparotomy
- ENT/strabismus
- Neurological
- Breast
Gan TJ, et al. Anesth Analg. 20039762-71.
17Other Risk Factors
- Type of surgery craniotomy, strabismus repair,
ENT surgery, major breast surgery, abdominal
surgery and GYN procedures - Metabolic factors chemotherapy, radiation
therapy, hormonal imbalances, pregnancy,
electrolyte disturbances, uremia, migraine
headaches, diabetes, pain, and some stages of
menstrual cycle
Kovac AL. Drugs .200059(2)213-243.
18Pediatric Specific
- Vomiting occurs twice as frequently in children
- Increases with age, decreases after puberty
Weak evidence Age and Duration of
surgery Conflicting evidence Type of surgery
19Risk Factors Supported by Strong Evidence
- Female gender
- History of PONV
- History of motion sickness
- Non-smoker
- Postop use/administration of opioids
- Use of volatile anesthetics
- Use of nitrous oxide
20Reduce Baseline Risk
- Regional anesthesia
- Propofol
- Supplemental oxygen
- Hydration
- Avoid nitrous/volatile anesthesia
- Minimize opioids/neostigmine
- Others
- Complementary and alternative modalities
(acupressure, acupuncture, TENS, ginger,
isopropyl alcohol, etc) - Behavioral intervention (guided imagery, music
therapy, relaxation, therapeutic touch, etc)
21Pre-Admission Testing Preop/Holding
- Recommendations
- Assess for risk factors using a simplified tool
- PONV Class I, Level A
- PDNV Class I, Level C
- Document communicate risk factor assessment
(Class I, Level A)
- Expected Outcome PONV/PDNV risk factors will be
- Identified prior to surgery
- Documented and communicated among surgical team
members - Appropriate PONV prophylaxis will be initiated as
indicated by risk factor assessment - The incidence of PONV will be reduced
- Patient satisfaction will be improved
22Simplified Risk Factor Tools
- Koivuranta et al, 1997
- Female gender
- Nonsmoker
- History of PONV/motion sickness
- Duration of surgery gt 60 min
- Apfel et al, 1999
- Female gender
- Nonsmoker
- History of PONV/motion sickness
- Postoperative opioids
Patients are assigned 1 point for each factor
present
Cameron D and Gan C. Anesthesiol Clin North
America. 200321 347-365. Apfel CC, et al.
Anesthesiology. 199991693-700.Koivuranta M, et
al. Anaesthesia. 199752443-449.
23Simplified Risk Factor
Apfel CC, et al. Anesthesiology. 199991693-700.
24American Society of PeriAnesthesia Nurses (2006)
25Selection of Interventions
- Selection of interventions should be based on
- Efficacy of the intervention
- Consideration of success rate
- Duration of action
- Risk of developing side effects or number and
severity of side effects - Cost
26Postoperative Patient Management
- Assess for PONV on admission, discharge, and more
frequently as indicated (Class I, Level C) - If nausea is present, quantify using a VDS/VAS
(Class I, Level C) - Implement rescue interventions
- Minimize movements or stimuli
- Avoid noxious odor
- Adequate hydration and oxygenation
- Separate preop and postop patients
- Comfort measures, cool wash cloth
- Avoid tight fitting oxygen masks
- Demonstrate slow deep breathing
Golembiewski J and OBrien D. J Perianesth Nurs.
200217(6)364-376.
27American Society of PeriAnesthesia Nurses (2006)
28Postoperative Patient Management Expected
Outcomes
- Routine assessment for the presence of PONV
- Initiate appropriate PONV rescue treatment
- The incidence of PONV will be reduced
- The incidence of rescue treatment will be reduced
- Patient satisfaction will be improved
Post Discharge Factors
- Narcotics for pain management
- That long ride home
- Motion
- Introduction of liquids
- Pain
29Post Discharge Nausea and VomitingPDNV
- Background
- Recent studies
- Patients responded by stopping pain meds
- 1/3 found nausea worse than expected
- None of 5 published algorithms list care for PDNV
patients - Lack of studies available that examine strategies
to decrease PDNV - PDNV underreported in past
- Care for patient with PDNV not standardized
- No studies detailing physician practices for
usual care - PDNV can affect patient recovery and resumption
of normal activities - Do not know how symptoms impact recovery, how
extensive the delay, or costs
Scuderi PE and Conlay LA. Int Anesthesiol Clin.
2003 41(4)165-74. Gan TJ. JAMA.
2002287(10)1233-1236. Odom-Forren J, et al. J
Perianesth Nurs. 200621(6)411-430. Wu CL,
Berenholtz SM, Pronovost PJ, Fleisher LA.
Anesthesiology. 2002 96(4)994-1003.
30Clinical Consequences of PDNV
- Patient discomfort and dissatisfaction
- Patient unpleasant experience
- Financial impact
- (Study Patients willing to pay 100 out of
pocket to prevent PONV) - Delayed in returning to work to normal
activities - Electrolyte imbalance and dehydration
- Unable to take in food by mouth
- Unnecessary trip back to the ED
- Unplanned admission
Odom-Forren J and Moser DK. Journal of Amb Surg.
20051299-105.
31 American Society of PeriAnesthesia Nurses
(2006)
32Questions ???
Thank you!
pwindle_at_sleh.com