Multimodal therapies for postoperative nausea and vomiting, and pain

Abstract

Postoperative nausea and vomiting (PONV) and pain are two of the major concerns for patients presenting for surgery. The causes of PONV are multifactorial and can largely be categorized as patient risk factors, anaesthetic technique, and surgical procedure. Antiemetics work on several different receptor sites to prevent or treat PONV. This is probably why numerous studies have now demonstrated that using more than one antiemetic is usually more effective and results in fewer side-effects than simply increasing the dose of a single antiemetic. A multimodal approach to PONV should not be limited to drug therapy alone but should involve a holistic approach starting before operation and continuing intraoperatively with risk reduction strategies to which are added prophylactic antiemetics according to the assessed patient risk for PONV. With the increasing understanding of the pathophysiology of acute pain, especially the occurrence of peripheral and central hypersensitization, it is unlikely that a single drug or intervention is sufficiently broad in its action to be adequately effective, especially with moderate or greater pain. Although morphine and its congeners are usually the foundation of pain management regimens, as their dose increases so does the incidence of side-effects. Thus, the approach for the management of acute postoperative pain is to use multiple drugs or modalities (e.g. regional anaesthesia) to maximize pain relief and reduce side-effects.

Improving Outcomes in Colorectal Surgery by Sequential Implementation of Multiple Standardized Care Programs

“…25,26 Anxiolytics are avoided and a multimodal approach to postoperative nausea and vomiting is used. 27 A prophylactic dose of unfractionated or low molecular weight heparin is given to reduce risk of venous thromboembolism (VTE). 28 Intraoperatively, goal-directed fluid administration is used with esophageal Doppler or noninvasive hemodynamic monitoring devices, [29][30][31] and minimally invasive surgery is used whenever possible.…”

What is the optimal postoperative oral feeding timing protocol for thoracotomy patients? Prospective randomized clinical trial on postoperative complications

“…Pulmonary complications are the most frequent complications seen after the operations performed under general anesthesia, caused by numerous factors summarized in Table 5, with an incidence of up to 50%; [3][4][5][6][7][8] majorly dependent to the impeded swallowing, traumatic discordance in pharyngeal structures, and alterations on the physiology of the gastrointestinal tract, [9][10][11][12][13][14] of which may last up to the postoperative 18 th hour. [15,16] Postoperative pulmonary complication incidence of our study was 18.7%, which revealed that male gender, smoking history, coexistence of COPD, and psychiatric complication occurrence were the factors associated with higher risk for post-thoracotomy pulmonary complication incidence; all in accordance with the current literature.…”

Hernia in Ambulatory Surgery Centre

“…For patients at moderate to high risk for PONV, regional anesthesia should be considered. If this is not possible or contraindicated and a general anesthesia is used, a multimodal approach that combines pharmacologic and nonpharmacological prophylaxis to minimize risk of PONV should be adopted [25,27].…”