Postop problem solved?

Thousands of patients have put off or even foregone needed surgery because of this fear, surveys suggest.

The worst-case scenario - patients suffocating to death on their own vomit in the post-anesthesia care unit (PACU) - is extremely unlikely thanks to extensive monitoring by perianesthesia nurses. But in severe cases, PONV can lead to dehydration and extend a hospital stay, to the consternation of patients and their families, and to the detriment of a hospital's bottom line.

"The patient's unsatisfactory experience in the hospital, along with the increased length of stay in the PACU, makes patients and their families very anxious," said Magdy Bishay, MD, an anesthesiologist at Lawrence Memorial Hospital of Medford, a member of Hallmark Health System. "In some cases the patient has to be admitted to the hospital overnight. All this increases the cost of OR personnel, medications and hospital bills."

Seven-Step Program

Researchers have developed medications called antiemetics and explored acupuncture and other alternative methods to reduce or eliminate PONV.

DeLeskey and other clinicians at Lawrence Memorial Hospital have developed a highly successful seven-step pilot program to prevent and/or minimize it.

"We decided to take an aggressive approach to improve PONV outcomes for our patients," she told ADVANCE.

It worked. During the pilot period, which lasted several months, no surgical patients experienced postop vomiting and only 5 percent reported feeling nauseous - to the delight of hospital administration.

DeLeskey introduced the pilot program in 2007 after completing a fellowship at The Joanna Briggs Institute, an international not-for-profit research and development organization in Australia that specializes in evidence-based resources for healthcare professionals.

The program's seven steps are:

• Assessing patients' risk level before surgery,

• Documenting patients' risk,

• Apprising the anesthesia team of patients' risk level,

• Leaving written orders with recovery room nurses for rescue treatment,

• Pre-treating patients based on postoperative nausea and vomiting risk,

• Continuously monitoring patients in the recovery room for nausea and vomiting, and

• Treating with medication immediately if patient becomes nauseous or begins to vomit.

"The healthcare system is thrilled with the success of the pilot program that has proven to reduce, and in many cases eliminate, postoperative nausea and vomiting," said Nancy Gaden, MS, RN, chief nursing officer/vice president for patient care services for Hallmark Health System.

"This is a real fear for many patients and being able to put their concerns to rest so they can focus on their surgery and subsequent recovery is just tremendous," she said.

Assessing Risk

According to a PONV-risk assessment scale, risk factors for PONV include being a woman, having a prior history of PONV, having a history of motion sickness, and undergoing treatment with narcotic analgesics during and following surgery.

Interestingly, smokers seem to have a lower risk for postop nausea.

"Patients having only one risk factor (i.e. female) are considered low risk for PONV," DeLeskey said. "Patients with two to three risk factors are at moderate risk for PONV, and patients with more than three risk factors have a severe risk."

Children are twice as likely as adults to develop PONV, according to guidelines on the problem published in 2006. Children are at highest risk when a surgical procedure lasts more than 30 minutes; when they are age 3 or older; when PONV runs in the family; and when the surgery is to correct strabismus, or crossed eyes.

Obesity does not increase a patient's chances of suffering from PONV, as previously thought, according to the guidelines.

At-risk patients "are generally medicated either preoperatively or intraoperatively, or both, in an attempt to preempt PONV," DeLeskey said. "The type of medication used is chosen by the anesthesia provider."

Bishay said he avoids general anesthesia and tries regional anesthesia to reduce baseline risk factors for PONV. "We use Propofol for induction and maintenance of anesthesia, for its antiemetic properties," he said.

He also recommended avoiding nitrous oxide and anesthetic gases, minimizing narcotics, minimizing muscle relaxant reversal via neostigmine and adequately hydrating the patient.

"Medications administered by the IV route take effect almost instantly, thereby negating the occurrence of vomiting most of the time," DeLeskey said. "Dexamethasone is a commonly used antiemetic nationally and is quite effective."

Antiemetics Routine

At Boston's Beth Israel Deaconess Medical Center (BIDMC), all patients are administered antiemetics intraoperatively, said Mary Grzybinski, BSN, RN, who estimated about 10 percent of BIDMC patients experience postop nausea.

"Although postop nausea can happen to anyone undergoing general anesthesia, it can happen more often in the gynecological surgeries," said Grzybinski, administrative clinical adviser in the PACU and pre-admission testing.

For patients with a high incidence of postop nausea, anesthesiologists administer two different antiemetics and also order scopolamine patches to be placed on patients the night before or the morning of surgery, she said.

"In severe cases we just continue to medicate with different types of antiemetics," she continued. "There are several kinds and what works for one doesn't necessarily work for all. If they can't keep anything down, we do not discontinue their intravenous hydration. We keep them hydrated with IV fluids as long as needed. If they are supposed to be discharged to home, we have them admitted."

Alternatives to Meds

Since medications are costly and entail potential side effects, the search continues to find simpler, non-invasive ways to control PONV.

Giving patients 100 percent oxygen during surgery - once a common preventive strategy - is no longer considered effective, nor is hypnosis, according to the 2006 guidelines.

But a 2009 study published in April in The Cochrane Library suggests the ancient Chinese practice of acupuncture - specifically, stimulating an acupoint in patients' wrists - can reduce symptoms. Stimulating the pericardium (P6) point in the wrist can be done by penetrating the skin at defined points with thin, metallic needles, as in traditional acupuncture, or by acupressure via a wristband that presses down on the point, according to the article.

Bishay is becoming convinced.

"In some cases, acupuncture, acupressure and acupoint stimulation have good antiemetic effect comparable to that of pharmacologic therapy," he said.

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