EvidenceBased Practice for Management of PONVPDNV: The ASPAN Guidelines

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Evidence-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

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PONV 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.

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Definitions

• 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.
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What 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.
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Incidence 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.
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Clinical 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.
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Childrens 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

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Vomiting Center

• Acts upon sensory input
• Activates efferent motor pathways
• Receptors
• Cholinergic
• Histamine
• Opioid
• NK1

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ASA 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.
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PONV/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
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Guidelines Are...

• NOT intended as standards or absolute
  requirements
• ARE to be adopted, modified, or rejected
  according to specific clinical needs or
  restraints

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Goals/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

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PONV Terms

• Nausea /or vomiting that occurs within the first
  24-hour period postoperatively following surgery

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PDNV Terms

• Nausea /or vomiting that occurs after discharge
  from the health care facility following surgery

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PONV/PDNV Guidelines 2006

• Available at
• www.aspan.org
• Endorsed by
• AANA
• ASA

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What 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.
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Other 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.
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Pediatric 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
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Risk 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

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Reduce 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)

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Pre-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

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Simplified 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.
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Simplified Risk Factor
Apfel CC, et al. Anesthesiology. 199991693-700.
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American Society of PeriAnesthesia Nurses (2006)
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Selection 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

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Postoperative 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.
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American Society of PeriAnesthesia Nurses (2006)
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Postoperative 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

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Post 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.
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Clinical 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.
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American Society of PeriAnesthesia Nurses
(2006)
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Questions ???
Thank you!
pwindle_at_sleh.com