Postoperative nausea and vomiting

Abstract

Postoperative nausea and vomiting (PONV) remains a common clinical problem that increases patient morbidity, healthcare costs and affects patient satisfaction. This article outlines the physiology, reviews the available drugs and suggests a structure using risk stratification that helps to plan sensible clinical management.Postoperative nausea and vomiting (PONV) has an incidence of up to 30% 1,2 and is one of the most feared side effects of anaesthesia, even above pain. 3 Although in most cases it is self-limiting, each episode of vomiting delays discharge from the recovery room, increases the risk of unplanned admission and may be associated with more severe complications including pulmonary aspiration, dehydration, electrolyte abnormalities, raised intra-cranial and intraocular pressures, wound dehiscence and oesophageal rupture.The management of PONV involves risk stratification, prevention and treatment. This can utilize both pharmacological and non-pharmacological interventions. DefinitionsNausea is the sensation of needing to vomit, which may include activation of central, sympathetic and parasympathetic responses.Vomiting is the involuntary oral expulsion of gastric contents via coordinated autonomic, gastrointestinal and respiratory system activity. It can be considered in two phases. In the pre-ejection phase, sympathetic activation causes tachypnoea, tachycardia, hypertension, diaphoresis, pallor and hypersalivation. During the ejection phase, the epiglottis closes and forceful coordination of diaphragm, abdominal musculature and oesophagogastric constrictors leads to forceful expulsion of gastric and upper duodenal contents. Pathophysiology of nausea and vomitingThe physiology of nausea and vomiting is complex and new pathways remain to be discovered. A good understanding of current knowledge helps explain the pharmacological targets and therapies detailed below. Two key areas of the brain are important in the action of vomiting: the vomiting centre and the chemoreceptor trigger zone (CTZ) (Figure 1). The vomiting center (VC)This lies in the lateral reticular formation of the medulla and receives afferent impulses via cranial nerves (CN) from the vestibulocochlear apparatus of the middle ear (CN VIII), carotid baroreceptor impulses (CN IX), gastrointestinal chemo-and stretch receptors (CN X) and aortic baroreceptors (CN X). It also receives afferents from higher cortical centres involved in pain, anticipation, memory, sight and fear as well as spinal cord afferents from peripheral pain pathways.The VC coordinates actions of the smooth and striated muscles involved in vomiting via the 'special visceral efferent nerves', CN V, VII, IX, X and XI. These innervate the muscles of the face, neck and oropharynx in a coordinated fashion. Motor, sympathetic and parasympathetic outflow to the gastrointestinal tract and secretory organs are carried by the autonomic general visceral efferents of CN II, VII, IX and X. Finally efferent branches from the VC travel via spinal nerves to the diaphragm and abdominal musc...

Polymorphisms of 5‐hydroxytryptamine receptor type 3B gene and clinical characteristics for vomiting after breast surgery in chinese han female population

“…Unaware of the genotypes of the subjects, the presence of vomiting was recorded on the worst day after surgery, which is usually during the first 24 h after the procedure. Vomiting was defined as the discharge of the stomach contents and nausea as a feeling prone to vomiting 12 …”

Incidence of post-operative nausea and vomiting and it’s predictors among adult elective surgical patients at Jimma Medical Center, South West Ethiopia

“…Although, it can occur in post-operative period during any time, the prevalence is large within 24 hrs. post operatively than after this hour (13).…”

“…They fall into: risk-reduction strategies, pharmacological interventions and non-pharmacological interventions (13,15). Firstly, the risk reduction strategies management of PONV should involve preventing maneuvers that provoke PONV and universal multimodal pharmacologic prophylaxis (16).Secondly, pharmacological interventions such as, H1 and H3 antagonists, Steroids and Phenothiazine are advocated as treatment (13,15). Lastly, acupuncture and acupressure has been postulated as non-pharmacological therapies prophylactic measure to prevent or reduce PONV (17).…”

Få pasienter opplever postoperativ kvalme etter dagkirurgi med multimodal kvalmestillende behandling

“…The exact pathophysiology of nausea and vomiting is complex, and many aspects remain unclear (3). The term 'postoperative nausea and vomiting' (PONV) is a generic term that includes nausea and/or vomiting following surgery (4,5).…”