PONV : The big little problem. Dr.Dewinter

Transcription

1 PONV : The big little problem. Dr.Dewinter

2 Introduction Definition Pathophysioloy Ponv risk factors and prognosis systems Antiemetics Ponv scheme Conclusion

3 Introduction Incidence of PONV : 30 % Most common complaint after GA Outcome parameters: Wellbeing patient satisfaction First guidelines : Gan TJ,Meyer T,Apfel CC, et al.consensus guidelines for managing postoperative nausea and vomiting.anesth Analg.2003;97:62-71

4 Definition Vomiting: actual oral expulsion of gastrointestinal contents Nausea: subjective feeling of the need to vomit

5 Pathophysiology Figure 86-1 Pathways for nausea and vomiting. Dotted lines are hypothetical pathways with only indirect evidence. (Created by Christian Apfel, MD, PhD.) Miller s Anesthesia seventh edition p.2730

6 Risk factors Dtsch Arztebl Int 2010; 107(42):

7 Prognosis systems Dtsch Arztebl Int 2010; 107(42):

8 Antiemetics Anticholinergics : scopolamine Dopamine antagonists: droperidol,alizapride 5-HT3 blockers: ondansetron,dolansetron, granisetron Corticosteroids: dexamethasone Antihistamines: promethazine Propofol

9 Anticholinergics Oldest class of antiemetic Scopolamine Muscarinic receptors:cerebral cortex,pons Dry mouth,drowsiness,impaired eye accomodation,sedation,confusion Motion sickness>ponv Iv, transdermal

10 Dopamine antagonists Benzamides Butyrophenones

11 Benzamides Domperidone,metoclopramide,alizapride Dopamine(D2)receptor antagonits Extrapyramidal effects,hypotension, neuroleptic syndrome,supraventriculaire tachycardia Domperidone and ventricular arrhythmia or sudden cardiac death: a populationbased case-control study in the Netherlands. van Noord C, Dieleman JP, van Herpen G, Verhamme K, Sturkenboom MC. Drug Saf Nov 1; 33(11):

12 Butyrophenones Droperidol,(haloperidol) Doses : mg As effective as ondansetron <-> headeache Anxiety,restlessness,akathisia Black box warning CI:parkinson s disease

13 Figure Prolongation of QTc interval after postoperative nausea and vomiting treatment by droperidol or ondansetron. (From Charbit B, Albaladejo P, Funck-Brentano C, et al: Prolongation of QTc interval after postoperative nausea and vomiting treatment by droperidol or ondansetron. Anesthesiology 102: , 2005.) Miller sanesthesia seventh edition p.2746

14 5-HT 3 antagonists Blocks serotonine(5 hydroxy-tryptamine) receptors centrally and peripherally Ondansetron,granisetron,dolasetron,tropisetron, palonosetron 25%overall risk reduction for ponv Metabolized by the liver Side effect:headache,constipation,mild asthenia prolongation QT interval

15 Corticosteroids Dexamethasone(5mg) Mechanism :unknown Before induction Co-analgetics,positively affect mood and convalescence

16 Antihistamines Phenothiazine derivative Promethazine(phenergan) Historically used Sedation,lethargy

17 Propofol 1981:Briggs&co:first mentioned the antiemetic effect Mechanism to prevent ponv:unclear Antiemetic effect is dose related Single dose propofol:unable to prevent ponv Subhypnotic dose:-1mg/kg/h -10mg bolus dose,continious infusion of 10µg/kg/min TIVA,TCI significant effect in ponv

18 Gan TJ,Glass PS,Howell ST,et al.determination of plasma concentrations of propofol associated with 50% reduction in postoperative nausea.anesthesiology 1997;87:

19 Venn diagrams for nausea, vomiting, and retching in patients after general inpatient or outpatient anesthesia with inhalational or propofol anesthesia. (From Visser K, Hassink EA, Bonsel GJ, et al: Randomized controlled trial of total intravenous anesthesia with propofol versus inhalation anesthesia with isoflurane-nitrous oxide: Postoperative nausea with vomiting and economic analysis. Anesthesiology 95: , 2001.)Miller s Anesthesia seventh edition p.2740

20 Novel antiemetics Palonosetron: Aprepitant: - a second generation 5HT3 receptor antagonist - prolonged duration of action - as effective as ondansetron mg effective dose - neuorokinin-1 receptor antagonist - prevention of ponv - oral dose of 40mg

21 Ponv scheme PONV Schema Evaluatie PONV risico Niet roker PONV 0,1,2,3,4 opiaten 10%,20%,40%,60%,80% POV risico kinderen >3j Chirurgie>=30 Strabisme POV 0,1,2,3,4 9%,10%,30%,55%,70% LAAG 10% MATIG 20% HOOG 30-60% ZEER HOOG >60% Anesthe 1. LRA 2. Propofol inductie en onderhoud 3. Geen N 2 O 4. O 2 supplement GEEN PROFYLAXIS MONO THERAPIE 2 COMBINATIE THERAPIE 3 COMBINATIE THERAPIE 5. Geen decurarisatie 6. Opiaat gebruik beperken DHB Of DXM Of Litican Of Ondansetron DHB of Ondansetron en DXM DHB en DXM en Ondansetron Profilactische dosis : DHB : 0,625mg (0,01-0,015mg/kg) DXM : 5mg (0,1-0,15mg/kg) Ondansetron : 4mg (0,1mg/kg) ( )kinderen DHB ONDANSETRON LITICAN DXM* ONDANSETRON** LITICAN** DHB** DXM*(**) ONDANSETRON ** DHB** LITICAN DXM**** LITICAN DHB *** ONDANSETRON*** DXM**** ( aprepitant) Therapeutische dosis : DHB : 0,625mg (0,01-0,015mg/kg) DXM : 5mg (0,1-0,15mg/kg) Ondansetron : 1mg (0,1mg/kg) Litican : mg aprepitant : 40mg(po) ( )kinderen * Werkt pas na 2h ** zo nog niet toegediend *** enkel zinvol te herhalen na 6h **** enkel zinvol te herhalen na 8h Dr. Geertrui Dewinter UZ Gasthuisberg Leuven 30/05/2011

22 Figure Reduction of PONV with ondansetron, dexamethasone, and droperidol when given alone or in combination. (From Apfel CC, Korttila K, Abdalla M, et al: A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 350: , 2004.)Miller s seventh edition p 2747

23 Conclusions Identify ponv risk factors High risk patients : always prophylaxis classes antiemetics:compatible,additive TIVA :anti-ponv effect Preemptive antiemetics treatment antiemetics