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?