Eliminating Postoperative Nausea and Vomiting in Outpatient Surgery with Multimodal Strategies including Low Doses of Nonsedating, Off-Patent Antiemetics: Is “Zero Tolerance“ Achievable?

Abstract

For ondansetron, dexamethasone, and droperidol (when used for prophylaxis), each is estimated to reduce risk of postoperative nausea and/or vomiting (PONV) by approximately 25%. Current consensus guidelines denote that patients with 0–1 risk factors still have a 10–20% risk of encountering PONV, but do not yet advocate routine prophylaxis for all patients with 10–20% risk. In ambulatory surgery, however, multimodal prophylaxis has gained favor, and our previously published experience with routine prophylaxis has yielded PONV rates below 10%. We now propose a “zero-tolerance” antiemetic algorithm for outpatients that involves routine prophylaxis by first avoiding volatile agents and opioids to the extent possible, using locoregional anesthesia, multimodal analgesia, and low doses of three nonsedating off-patent antiemetics. Routine oral administration (immediately on arrival to the ambulatory surgery suite) of perphenazine 8 mg (antidopaminergic) or cyclizine 50 mg (antihistamine), is followed by dexamethasone 4 mg i.v. after anesthesia induction (dexamethasone is avoided in diabetic patients). At the end of surgery, ondansetron (4 mg i.v., now off-patent) is added. Rescue therapy consists of avoiding unnecessary repeat doses of drugs acting by the same mechanism: haloperidol 2 mg i.v. (antidopaminergic) is prescribed for patients pretreated with cyclizine or promethazine 6.25 mg i.v. (antihistamine) for patients having been pretreated with perphenazine. If available, a consultation for therapeutic acupuncture procedure is ordered. Our approach toward “zero tolerance” of PONV emphasizes liberal identification of and prophylaxis against common risks.

General Health and Knee Function Outcomes from 7 Days to 12 Weeks After Spinal Anesthesia and Multimodal Analgesia for Anterior Cruciate Ligament Reconstruction

“…Finally, the costs of avoided unplanned hospital admission 21 and pain-related hospital readmission 29 have been elucidated. One levobupivacine infusion patient in our study returned to the emergency department for extrapyramidal symptoms 30 and pain control after a hamstring autograft (the sciatic nerve was not blocked preoperatively per protocol); there were no other unplanned hospital admissions, readmissions or emergency room visits for pain control throughout our study. Therefore, the inconvenience of perineural catheter placement for the practitioner appears to be offset by the myriad health care system benefits, as well as patient benefits in the first few days after surgery, with no apparent patient-reported long-term detriment based on validated outcome surveys.…”

Anesthesia outside the operating room in the office-based setting

“…OBA PONV remains a challenge with an occurrence rate ranging from 25 to 30% 24 h after surgical procedure and as high as 70% in high-risk patients [28][29][30].…”

“…Skledar et al [28] took a much more aggressive approach PONV in an effort to reduce the occurrence to zero. To achieve this goal, they limit the use of volatile inhalation agents and opioids by using more locoregional anesthesia and multimodal anesthesia techniques and provide three doses of nonsedating off-patent antiemetics.…”

“…PONV in outpatients (prophylaxis and treatment): a 'zero-tolerance' strategy proposal (reproduced from[28])COX-2, cyclooxygenase2; i.v., intravenous; NSAID, nonsteroidal anti-inflammatory drug; PONV, postoperative nausea and vomiting.…”

Regional anesthesia and ambulatory surgery

“…These coinciding advances have improved patient care and cost savings via facilitating Phase 1 PACU bypass and/or early discharge [7 & ,8 & ]. This review of common regional anesthesia techniques will also describe anesthesia care plans designed to achieve faster PACU discharge if not Phase 1 bypass when accompanied by multimodal sedation-hypnosis, multimodal PONV prophylaxis [16,17], and multimodal analgesia.…”