Post Operative Nausea and Vomiting

POST OPERATIVE NAUSEA AND VOMITING

Robert Ferrante

Pharmacy Candidate

Objectives• Discuss the prevalence of Post Operative Nausea and

Vomiting (PONV) and why reducing PONV is so important to hospitals

• Review the evolution of PONV treatment• Examine the current medications used for PONV

Post Operative Nausea and Vomiting(PONV)1

• Up to 35% of ambulatory patients affected• 70% of high risk patients

• Number one concern of patients• … above pain, death, and MI

• Patients often classified by risk

Risk Factors

• Younger• Female• “Large body habitus”• History of:

• PONV• Motion Sickness• Anxiety

• Procedures:• Head/Neck• Intraabdominal• Larparoscopic• Gynecologic

• Medications:• Opiods

Why So Important?• Medical Consequences

• Patient satisfaction

• Shorter PACU stays • More patients

• MORE MONEY• Mo’ Problems?

http://www.frca.co.uk/article.aspx?articleid=354#faq

Antiemetics

https://www.inkling.com/read/pharmacology-brenner-stevens-4th/chapter-28/figure-28-3

Droperidol3

• Potent D2 Receptor antagonist

• PONV: 0.625-1.25 mg IM/IV Q3-4h

• Adjust for renal, hepatic, and age-related factors.• 75% renal elimination• Extensive liver metabolism• T ½ - 135 mins

Droperidol Brief History1,2,3

• Droperidol was the foundation for PONV• Effective and inexpensive

• December 2001: FDA issue BBW• Arrhythmic-Effects

• Heavily disputed.

• Should be reserved for resistant patients• Requires excessive monitoring

• ECG • Cost increase

Droperidol3

• Contraindications• First line treatment for anything but PONV• Known or suspected QT interval

• Major drug interactions• Drugs that may cause QT prolongation

• Including antiarrhythmics, opiods antipsychotics, and, diuretics

Reglan (Metoclopramide)4

• MOA:• Peripheral dopamine receptor inhibiton• Sensitizes tissues to acetylcholine (does not stimulate).

• Postoperative nausea and vomiting: 10 to 20 mg IV/IM every 4 to 6 hours as needed• CrCl < 40mL/min: 50% dose• Geriatric: Initiate at 50% dose

• Adverse Effects:• Asthenia• Headache, Fatigue, Somnolence• N/V

Reglan (Metoclopramide)• BBW – Tardive dyskinesia

• Contraindications:• Concomitant use with drugs likely to cause extrapyramidal

reactions • Epilepsy• Gastrointestinal hemorrhage, mechanical obstruction, or

perforation.

• REMS program required for other Indications

Reglan Efficacy5

• Metoclopramide vs Ondansetron• According to a meta-analysis of 54 studies, metoclopramide is as

effective as ondansetron in preventing postoperative nausea (59% vs 48%, respectively; p = 0.125)

• Metoclopramide prevented postoperative vomiting in only 35% of patients compared with 50% of those using ondansetron (p < 0.001)

• Metoclopramide vs Droperidol• Metoclopramide was inferior to droperidol in preventing both

postoperative nausea and vomiting. • The incidence of nausea was 41% for droperidol and 52% for

metoclopramide (p < 0.008); • The incidence of vomiting was 26% for droperidol versus 34% for

metoclopramide (p < 0.001)

Aloxi (Palonosetron)6

• PONV; Prophylaxis: 0.075 mg IV as a single dose immediately before induction of anesthesia Major side effects • No Dose adjustments!

• Contraindications?... Not really• Pregnancy Category B• Major drug interactions?... Not really…

• Apomorphine

Aloxi (Palonosetron)

• Adverse Effects:• Bradyarrhythmia (1-4%)• Constipation (5%)• Headache (9%)

• One vial = about $400

Aloxi Vs. Ondansetron7

• A Randomized, Double-blind Trial of Palonosetron Compared with Ondansetron in Preventing Postoperative Nausea and Vomiting after Gynaecological Laparoscopic Surgery.

• Study design:• Induced with propofol• Intubated with rocuronium• NM blockade reversed with pyridostigmine and glycopyrolate

Aloxi Vs. Ondansetron7

• 0.075 mg Palonosetron , n = 45• 8 mg Ondansetron, n = 45

• Results:• Over 24 hours, overall PONV in 30 ondansetron patients, 19 in

palonosetron• Rescue antiemetics were used in an equal number of patients

• Adverse Events:• Headache, Dizziness, Constipation, Myalgia

• Basically the same

• Patient Satisfaction:• 21 in ondansetron• 30 in palonosetron

References• 1.) Ting, P. Post-operative Nausea and Vomiting (PONV): An Overview. Available

from http://anesthesiologyinfo.com/articles/04252004.php• 2.) Brenner GM, Stevens CW. Pharmacology. 4th Edition. Tulsa, OK. 2013• 3.) Cherry W. Jackson, Amy Heck Sheehan, Jennifer G. Reddan. Evidence-Based

Review of the Black-box Warning for Droperidol. Am J Health Syst Pharm. 2007;64(11):1174-1186. 

• 4.) Metoclopramide. In: DRUGDEX Evaluations [database on the Internet]. Greenwood Village (CO): Thompson Micromedex; 1974-2014 [cited 18 Sep 2014].

• 5.) Domino KB, Anderson EA, Polissar NL, Posner KL. Comparative efficacy and safety of ondansetron, droperidol, and metoclopramide for preventing postoperative nausea and vomiting: a meta-analysis. Anesth Analg 1999;88:1370-9.

• 6.) Palonosetron. In: DRUGDEX Evaluations [database on the Internet]. Greenwood Village (CO): Thompson Micromedex; 1974-2014 [cited 18 Sep 2014].

• 7.)Park SK, Cho EJ. A Randomized, Double-blind Trial of Palonsetron Compared with Ondansetron in Preventing Postoperative Nausea and Vomiting after Gynaecological Lapaoscopic Surgery. J Int Med Res. 2011 39: 399

Questions?