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Postoperative nausea and vomiting (PONV) is a common complication, can make the patient's postoperative recovery satisfaction decreased. PONV can lead to further continue the adverse consequences (such as aspiration pneumonia, dehydration, esophageal tear, wound dehiscence), the patient received prolonged hospitalization or accidents 1. Despite ongoing research and the emergence of new drugs, but appeared in PONV after 24h 25% of patients still -30% 2,3.
By a multidisciplinary research team developed the following specialist treatment and management of PONV Guide Source: Medical Education Network www.med66.com. This guide is based on evidence-based medicine (when the lack of evidence, expert opinion under)-based, panel members reached a consensus established. If the panel about an issue can not reach a consensus to set out the majority view, and indicate the differences. Collected Medical Education Network
Guidance in the development process, the research team that preventive treatment for PONV can benefit low-risk patients should therefore be limited to the height and medium risk patients. Health care workers and patients should jointly determine the prophylactic antiemetic therapy is appropriate.
Panel treatment of PONV in the development and management proposals to consider the following factors: the level of risk PONV patients; PONV may lead to potential complications; the efficacy of various antiemetic drugs; antiemetic drugs cause side-effects; antiemetic treatment needs costs; PONV caused by the increase in medical costs.
Guideline 1: Make sure an adult with a high risk of PONV
Prophylactic antiemetic treatment is not applicable to all patients. PONV with moderate or high risk patients most likely to benefit from preventive antiemetic treatment. Therefore, the recognition of such patients is essential. Have clear risk factors include patient factors, anesthetic factors, and surgical factors.
Patient-related risk factors include women, who have a history of PONV or motion sickness, do not smoke 4-6. Anesthesia-related risk factors include intraoperative volatile anesthetics 7, intraoperative and postoperative opioid 4,4-11, the use of nitrous oxide 9. Factors related to surgical procedure type and duration of surgery. 5 lengthy surgery or nerve surgery, breast surgery, gynecological laparoscopy, open surgery, plastic surgery and eye - ear - nose - throat surgery 5,12,13 The patients had a higher risk of PONV. Source: Medical Education Network www.med66.com
Apfel, such as design a simplified risk score, recently used effectively for patients. According to the following four main predictors of PONV: female, no smoking, PONV or motion sickness, history of postoperative opioids, with 0,1,2,3,4 a predictor of risk of patients experiencing PONV, respectively, 10%, 20%, 40%, 60%, and 80%.
Table 1 outlines the risk factors for PONV in adults.
Table 1: risk factors for adult PONV
Do not smoke
History of PONV or motion sickness
Anesthesia risk factors
Intraoperative application of volatile anesthetics
Intraoperative and postoperative opioid
Procedure-related risk factors
Operation time (operation time for each additional 30-min, PONV risk increased by 60%, so after 30min, PONV baseline risk increased from 10% to 16%)
Type of surgery (laparoscopy, ear - nose - throat surgery, neurological surgery, breast surgery, strabismus surgery, abdominal surgery, plastic surgery)
Guide 2: Confirmation of high risk of vomiting after surgery for children
Prophylactic antiemetic treatment in favor of high risk of postoperative vomiting in children. Because children are difficult to describe the feeling of nausea, vomiting, so only the study and treatment of children, known as postoperative vomiting (POV). Rare in children under 2 years old POV, before puberty, POV incidence increases with age, decreased gradually after puberty. POV in children older than 3 years was 40% or higher. Before puberty, POV no gender differences in the incidence of 15.
Some surgical procedures may be related to higher incidence of POV in children: adeno tonsillectomy, strabismus repair, orchiopexy, penis surgery and inguinal hernia repair 2.
Most adults and children vomiting and risk factors are similar, however, important differences between the two, see summary table 2.
Table 2: risk factors for children POV
Risk factors and vomiting of children similar to adults, there are the following differences:
Research in children is limited to vomiting, nausea is not resolved the problem.
The incidence of vomiting in children 2 times for adults.
The risk of POV in children increases with age, decreased gradually after puberty.
Before puberty the incidence of POV was no gender difference.
POV specific increased risk of surgery.
Guideline 3: Reduce risk factors for PONV baseline
When clinically feasible, lowering the patient's baseline risk factors can significantly reduce the incidence of PONV. The following strategies can effectively reduce the baseline risk of patients, many have become multi-angle to minimize PONV measures as part of combination therapy 16.
Visser and other large sample, randomized controlled study showed that intravenous infusion of propofol instead of volatile anesthetics for anesthesia induction and maintenance can reduce the incidence of early postoperative nausea and vomiting rate (after 0-6h) 17. Avoid the use of volatile anesthetics and nitrous oxide 18,19 7 can reduce the incidence of PONV. Limit postoperative dose of neostigmine (2.5mg) reduced PONV20. Sinclair, etc. One study showed that compared with general anesthesia, using local anesthesia during surgery decrease the incidence of PONV 11 times 5. A randomized controlled trial showed that intravenous infusion of expansion treatment can reduce the incidence of PONV 21. Further small sample of randomized controlled trials confirmed that perioperative supplemental oxygen (80%), nausea and vomiting after surgery can halve the risk 22,23. Finally, according to a systematic review and random or non-randomized experimental results, intraoperative and postoperative use of minimum doses of opioids can reduce the incidence of PONV 4,8-11. Table 3 summarizes the baseline to reduce the risk PONV patients the main strategy.
Multi-angle combination therapy
Prevention of PONV should be used for multi-angle combination. Just make sure the patient has a high risk of PONV, they should avoid or reduce the emetogenic stimulus. Treatment including the application of sedative drugs (benzodiazepines class), adequate fluids, prophylactic antiemetic drugs (combination therapy should be considered), total intravenous anesthesia (propofol), effective analgesia (local anesthetic application, COX-2 inhibitors or other NSAIDS), supplemental oxygen and non-drug treatment (acupuncture, electro acupuncture and hypnosis) 16.
Table 3: Reduce the risk of PONV based strategy
Application of local anesthesia
Anesthesia was induced with propofol and maintained
Intraoperative supplemental oxygen
Avoid the use of nitrous oxide
Avoid the use of volatile anesthetics
Minimal intraoperative and postoperative opioid doses with minimal doses of neostigmine
Guide 4: Adult PONV prophylactic antiemetic therapy
5-HT3 receptor antagonist
5-HT3 receptor antagonist for the prevention and treatment of PONV, the efficacy of the end of surgery to give the best 24,25. 5-HT3 receptor antagonists prevention is better than the prevention of nausea and vomiting. Endanxiqiong, dolasetron, granisetron, and fewer side effects Toby Shillong. Panel that, when used to prevent PONV, there was no evidence that the 5-HT3 receptor antagonist efficacy and safety between the different 26,27.
Antiemetic effect of cortisol mechanism is still not clear. Dexamethasone can be effective in treating PONV, especially given before induction of anesthesia (but not the end of surgery), the cure of early postoperative nausea and vomiting (0-2h). The most common adult dose is 8-10mgI.V.29. Can be applied to small doses of 2.5-5mg, also proved to be effective 30,31. According to a large number of systematic review data, no single side effect of dexamethasone 29.
Neural antipsychotic drugs droperidol anesthesia is widely used in the prevention of PONV, prevention effect Endanxiqiong quite 32. Droperidol should be given to the end of surgery 33 or with morphine for PCA, to maximize their efficacy 34. Large doses of droperidol may be the typical side effects (hypotension, extrapyramidal reactions, *** can not and irritability), application of smaller doses (0.625-1.25mg) may occur 35.
In 2001, the U.S. Food and Safety Administration began requiring the labeling of droperidol should be provided in the "black box" warning, indicating the drug may lead to death or life-threatening QT prolongation and torsades de pointes ventricular tachycardia. This request is based on the market about 30 years, the application of droperidol (1.25mg or more doses) of the ten reported cases of 36. However, in the previous literature review, droperidol dose for the treatment of PONV, no QT interval prolongation, arrhythmia, or death has been reported 16.
Before the end of the night before surgery or anesthesia 4h application of transdermal scopolamine can produce antiemetic effects. The end of surgery intravenous phenothiazines, promethazine, and chlorine can be effective antiemetic 37,38 pyrazine. These drugs can cause sedation, dry mouth and dizziness.
Before surgery using acupuncture, massage, transdermal electrical nerve stimulation, acupoint stimulation, and hypnosis and other non-drug treatment may also have antiemetic effects 39.
Part to lack of evidence
Metoclopramide is a phenylpropanoid amides, most members of the panel is not recommended for the clinical standard dose (10mg) for PONV treatment, but the group did not reach consensus.
Table 4 lists the composition of people of a prophylactic antiemetic treatment commonly used drugs, including the appropriate dose and administration time.
Table 4: Adult antiemetic drug dose and administration time
Delivery time: before induction
Dexamethasone 5-10 mg I.V.
Delivery time: the end of surgery
Dolasetron 12.5mg I.V.
Droperidol 0.625-1.25mg I.V.
Granisetron 0.35-1mg I.V.
Endanxiqiong 4-8mg I.V.
Chloro pyrazine 5-10mg I.V.
Promethazine 12.5-25mg I.V.
Toby Shillong 5mg I.V.
Delivery time: the night before surgery or anesthesia before the end of 4h
Scopolamine transdermal patch
Guide 5: Prophylactic antiemetic treatment of POV in children
As children, the incidence of POV 2 times 2 adults and therefore may need more than adults preventive antiemetic treatment. 5-HT3 receptor antagonist is the prevention of POV in children first-line drugs. Perphenazine (based on two large randomized controlled study results 40,41), diphenhydramine and dexamethasone (29,42 based on the results of meta-analysis) can also be effective in preventing children POV. Application of droperidol in children after an increased risk of extrapyramidal reactions, so the only hospital for children with other treatments ineffective.
Table 5 prophylactic antiemetic for the treatment of common pediatric drugs, including the right dose.
Table 5: Children's doses of antiemetic drugs
Maximum dose of 8mg dexamethasone 150ug/kg
Maximum dose of dolasetron 12.5mg 350ug/kg
Maximum dose of droperidol 1.25mg 50-75ug/kg
Endanxiqiong 50-100ug/kg maximum dose 4mg
Perphenazine 70 ug / kg
Guide 6: For patients with a high risk of PONV should take preventive measures, and moderate risk of PONV in patients using prophylactic antiemetic therapy may be considered
If the low-risk patients PONV prophylactic antiemetic therapy is also used routinely, may be unnecessary to make the patient the potential side effects. Antiemetic therapy on risk - benefit assessment become increasingly cautious. Medium or high risk of PONV should consider using local anesthesia patients; use of general anesthesia should minimize the baseline risk factors and to consider the application of non-drug treatment measures. Medium or high risk of PONV in patients most likely to benefit from preventive treatment. Unless the vomiting can lead to serious medical consequences, otherwise low-risk patients do not need preventive treatment.
Patients at risk for PONV secondary to a single antiemetic therapy (adults) or combination (adults and children), combined with high-risk patients should be 2-3 different classes of antiemetic drugs. Different mechanism of action of drugs in combination can produce the best results. Such as the 5-HT3 receptor antagonists (anti-vomiting more effectively) with droperidol (anti-nausea and more effective) combination.
Guide 7: did not receive prophylactic antiemetic therapy or treatment failure of the patients experienced PONV treatment when
After the patient left the recovery room may be nausea and vomiting. Ruled out drugs and mechanical reasons, the anti-vomiting remedy should start treatment. Did not receive prophylactic antiemetic therapy for patients, can be applied to low-dose 5-HT3 receptor antagonist 45. At this point some of PONV treatment of 5-HT3 receptor antagonist for the prevention of the dose dose 1 / 446. 5-HT3 receptor antagonist antiemetic therapy is remedial alternative drugs, but the smaller dose and efficacy data .
According to expert opinion, research team developed specialized antiemetic treatment guidelines, divided into the following three conditions: preventive dexamethasone for treatment failure patients, recommend low-dose 5-HT3 receptor antagonist. For those who started on the application of 5-HT3 receptor antagonists for preventive treatment failure patients should not be used within 6h after 5-HT3 receptor antagonists for remedial treatment. Similarly, those who combined 5-HT3 receptor antagonist and dexamethasone for preventive treatment failure patients, it also should use other types of antiemetic drugs for treatment.
As a general guide, PONV occurred within 6h after the patients, preventive therapy should be used with different classes of antiemetic drugs. PONV for the postoperative patients after 6h, repeatable application of preventive programs in medicine - dexamethasone and transdermal scopolamine, except for a longer duration of action. With monitoring the conditions, can be applied to a small dose of propofol treatment PONV.
Table 6 did not receive prophylactic antiemetic therapy or treatment failure of the patients experienced PONV during the recommended treatment.
Table 6: did not receive prophylactic antiemetic therapy or treatment failure of the patients experienced PONV antiemetic therapy when
If the initial therapy for the treatment measures that
Dexamethasone or preventive treatment of small doses of 5-HT3 receptor antagonists *
5-HT3 receptor antagonist plus another drug # use different kinds of drugs
5-HT3 receptor antagonists and the other two drugs appeared in PONV after 6h of patients: use of different
Class of antiemetic drugs or application of isoproterenol in the recovery room
6h PONV after surgery patients: repeated application of
5-HT3 receptor antagonists and scopolamine (to plug
Musson and transdermal scopolamine excluded)
Different types of drugs used
* Small doses of 5-HT3 receptor antagonist: Endanxiqiong 1.0mg, dolasetron 12.5mg, granisetron 0.1mg, and Toby Shillong 0.5mg.
# Remedial treatment options: droperidol 0.625mg IV, dexamethasone (2-4 mg IV), and promethazine 12.5 mg IV.
PONV in patients with the best risk management guidelines for clinicians to provide the evidence-based medicine tools. First, the guidelines suggest that clinicians recognized with moderate or high risk of PONV in patients, because the low-risk patients can not benefit from preventive treatment. Subsequently, the lower the risk of moderate or high degree of PONV baseline risk of patients. Consider the multi-angle comprehensive treatment PONV, including the application of antiemetic drugs, analgesics and sedatives; fluid; supplemental oxygen and total intravenous anesthesia. A high risk of PONV for adults and children with moderate to high risk of the combined treatment should be carried out.
Fujii Y. / Tanaka H. / Ito M. [Dr. Y. Fujii. Department 0f Anesthesiology, University Of Tsukuba. Insti. tute 0f Clinical Medicine ,2-1-1. Amakubo. Tsukuba City, Ibaraki305-8576, Japan] a ARCH. OPHTHALMOL. 2005,123 / 1 (25-28)
Background: Postoperative vomiting children strabismus surgery (POV) remains a major problem. Objective: To evaluate single dose ramosetron - a new type of a serotonin antagonist 5, strabismus surgery in children receiving prevention of POV in the effectiveness and safety. Methods: A prospective, randomized, double-blind placebo-controlled study, 80 patients (38 males, 42 females) aged 4 to 10 ready to accept children with strabismus surgery, the end of surgery intravitreal injection comfort agent or ramosetron, ramosetron dose were the following 3 different doses of 1 species: 3 p. g / kg, 6 Î¼g / kg or 12Î¼g/kg (n = 20). Standard general anesthesia. MAIN OUTCOME MEASURES: anesthesia and the second after the first 24 h (ie 0 ~ 24 h and 24 ~ 48 h), recorded onset of vomiting and safety evaluation. Results: O ~ 24 h after anesthesia in patients without vomiting (defined as no retching and no vomiting) and the placebo group (25%) compared to a dose of 3 wg / kg of ramosetron injection group was 35% ( P = 0.37), 6Î¼g/kg ramosetron group was 90% (P = 0.001), 12Î¼g/kg ramosetron injection group was 90% (P = 0.001). 24 ~ 48 h after anesthesia during the corresponding rates of no vomiting in each group with the placebo group (30%), respectively, compared to 40% (P = O.371), 90% (P = 0.001), 90% ( P = 0.001). Observed in each group were not clinically significant adverse reactions. Conclusion: Strabismus surgery for the prevention of children receiving O ~ 48 h after anesthesia in the incidence of POV, 6Î¼g/kg dose Remo Division Qiongji this enough, but 3Î¼g/kg dose is inadequate. The dose will be increased ramosetron to 12Î¼g/kg did not show better results.
Medical HEALTH "> Medical>> Pediatrics>> Abstract Ondansetron anesthesia in children to prevent nausea and vomiting after comments recommend download the full text of the clinical observation of this paper, Sun Zhen Lixin Na Collection Second Clinical College, China Medical University, Department of Anesthesiology," Pediatric Emergency Medicine "1998 No