Gastrointestinal and urinary complications in the postoperative period

Transcription

1 The 13 th Annual Perioperative Medicine Summit Fort Lauderdale, Florida Gastrointestinal and urinary complications in the postoperative period Dan Hunt, MD Professor of Medicine Director, Division of Hospital Medicine Emory University School of Medicine

2 2018 Perioperative Medicine Summit March 7-10, 2018 Gastrointestinal and urinary complications in the postoperative period Dan Hunt MD has disclosed that there is no actual or potential conflict of interest in regards to this presentation The planners, editors, faculty and reviewers of this activity have no relevant financial relationships to disclose. This presentation was created without any commercial support.

3 Objectives: Postoperative nausea/vomiting (PONV) Postoperative ileus (POGD) Postoperative urinary retention (POUR)

4 What are the risks for postoperative nausea/vomiting, ileus, and urinary retention? Why do we care? Why should we care A LOT?

5 PONV

6 Fero KE et al. Pharmacologic management of postoperative nausea and vomiting. Expert Opin Pharmacother 2011; 12:

7 Gan TJ et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014; 118:85-113

8 Horn CC et al. Pathophysiological and neurochemical mechanisms of postoperative nausea and vomiting. Eur J Pharmacol 2014 January 5; 722:55-66

9 Strategies to reduce baseline risk Use regional anesthesia instead of general Use of propofol for induction and maintenance Avoidance of nitrous oxide Avoidance of volatile anesthetics Minimize intraoperative and postoperative opioids Adequate hydration Gan TJ et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014; 118:85-113

10 Drugs for prevention of PONV Class Drug Dose Timing Phenothiazines Promethazine mg IV Butyrophenones Haloperidol mg IM/IV Droperidol mg IV End of surgery Benzamides Metoclorpramide Anticholinergics Scopolamine Transdermal patch Prior evening or 2 hours before surgery Antihistamines Hydroxyzine Dimenhydrinate 1 mg/kg IV 5-hydroxytyramine-3 antagonists Ondansetron 4 mg IV End of surgery Palonosetron mg IV At induction NK-1 (Neurokinin-1) antagonists Dolasetron 12.5 mg IV End of surgery Granisetron mg IV End of surgery Aprepitant 40 mg PO At induction Steroids Dexamethasone 4-5 mg IV At induction Methylprednisolone 40 mg IV

11 Risk factors: Female gender H/O PONV or motion sickness Non-smoking history Postoperative opioids TDS = transdermal scopolamine TIVA = total intravenous anesthesia Fero KE et al. Pharmacological management of postoperative nausea and vomiting. Expert Opin Pharmacother 2011; 12:

12 Gan TJ et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014; 118:85-113

13 Gan TJ et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014; 118:85-113

14 POGD (Postoperative gastrointestinal dysfunction)

15 Ileus Latin: ileos = severe colic Greek: eilein = to turn, squeeze Experts: postoperative ileus = prevents oral intake, occurs after a surgical intervention, and is due to nonmechanical causes

16 Hedrick TL et al. American Society for enhanced recovery and perioperative quality initiative joint consensus statement on postoperative gastrointestinal dysfunction within an enhanced recovery pathway for elective colorectal surgery. Anesth Analg 2017

17 Hedrick TL et al. American Society for enhanced recovery and perioperative quality initiative joint consensus statement on postoperative gastrointestinal dysfunction within an enhanced recovery pathway for elective colorectal surgery. Anesth Analg 2017

18 Hedrick TL et al. American Society for enhanced recovery and perioperative quality initiative joint consensus statement on postoperative gastrointestinal dysfunction within an enhanced recovery pathway for elective colorectal surgery. Anesth Analg 2017

19 POUR

20 Acute urinary retention is one of the few true urologic emergencies International Incontinence Society Definition: painful, palpable or percussible bladder, when the patient is unable to pass any urine Kowalik U and Plante MK. Urinary retention in surgical patients. Surg Clin N Am 2016; 96:

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23 Darrah DM et al. Postoperative urinary retention. Anesthesiology Clinics 2009; 27:

24 Risk factors for POUR Preoperative Intraoperative Postoperative Age > 50 Male Inguinal hernia repair, anorectal surgery Pre-existent urinary obstructive symptoms Previous pelvic surgery Neurological disease Perioperative medications (alpha blocker, beta blocker) Large amount of IVF (>750 ml) in anorectal and inguinal surgery Long duration surgery Spinal anesthesia High dose opioids Epidural anesthesia Opioids Bladder volume on arrival to PACU > 270 ml Sedative medications (midazolam) Postoperative analgesia Continuous epidural Patient-controlled epidural Baldini G et al. Postoperative urinary retention: Anesthetic and perioperative considerations. Anesthesiology 2009; 110:

25 Drugs Verhamme KMC et al. Drug-induced urinary retention. Incidence, management and prevention. Drug Safety 2008; 31:

26 Kowalik U and Plante MK. Urinary retention in surgical patients. Surg Clin N Am 2016; 96:

27 POUR..Diagnosis

28 POUR.Treatment Volume of urine drained in 15 min Approach >400 cc Leave catheter in place cc Clinical decision-intermittent catheter? <200 cc Pull catheter, re-think diagnosis

29 Quick POUR points: Should everyone undergoing spinal anesthesia for total hip arthroplasty receive a urinary catheter? RCT, 200 patients Protocol for no-catheter group: Results: Urinary retention Catheter (N=107) 3 (2.8%) [after catheter out] No catheter (N=93) 9 (9.7%) UTI 3 (2.8%) 0 (0%) Miller AG et al. J Bone Joint Surg Am 2013; 95:

30 Indwelling urinary catheter versus intermittent catheterization? 2015 Cochrane review: Not enough evidence Kidd EA et al. Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterization in hospitalized patients. Cochrane Database of Systematic Reviews 2015, Issue 12, Art. No.: CD004203

31 Should we prescribe alpha blockers (tamsulosin, alfuzosin, prazosin) for men with acute urinary retention? 2014 Cochrane Review: Some evidence to suggest increased success rates of trial without catheter. Able to void spontaneously after catheter removed Alpha blocker Placebo 366/608 (60.2%) 185/486 (38.1%) Incidence of side effects was low Fisher E et al. The role of alpha blockers prior to removal of urethral catheter for acute urinary retention in men. Cochrane Database of Systematic Reviews 2014; Issue 6. Art. No.: CD006744

32 What have we covered? Postoperative nausea/vomiting (PONV) Postoperative ileus (POGD) Postoperative urinary retention (POUR)