Postoperative Nausea and Vomiting in Adults: Implications for Critical Care

the literature vary according to theresearch study and the investigators’description. The most commonoperational definitions are the onespublished by the American Societyof PeriAnesthesia Nurses (ASPAN),7

which define PONV as nausea andvomiting that occurs within the first24 hours after surgery.

PathophysiologySystematic reviews and meta-

analysis have been used to determinepredictors of postoperative vomiting(Table 1); however, an understand-ing of risk factors is lacking becauseknowledge of the pathophysiologyof vomiting at the cellular and molec-ular level is incomplete.4,6-8 The bio-logical responses of nausea andvomiting are not identical. Theanalysis of each one is vital to pre-dicting a patient’s response.

Each person has a differentthreshold for stimulation of nauseaand vomiting. The known mecha-nisms for PONV are the pathwaysfor neural stimulation that initiate avomiting response. Nausea and vom-iting are under control of the centralnervous system via the vomitingcenter in the medulla oblongata andthe chemoreceptor trigger zone

Angela Smith Collins, RN, DSN, ACNS BC, CCNS

Postoperative Nausea and Vomiting in Adults: Implications for Critical Care

Postanesthesia Care

hypertension, bleeding, andincreased intracranial pressure.3-5

Lifesaving surgical interventioncompresses the time frame avail-able for preoperative assessment.4,5

Identification of high-risk patients,vigilance by health care providers,and multimodal interventions candecrease the incidence and severityof nausea and vomiting after sur-gery.6 Critical care areas can be struc-tured by design or protocol to bypasspostanesthesia areas. Althoughpatients may bypass a geographicsite, attentiveness to patients’ con-cerns mandates that professionalsin critical care translate current evi-dence into standards of care.

PONV has been associated withadministration of anesthetic agentssince the 1800s.4 The definitions in

One attribute of excel-lence in critical careis the degree of atten-tiveness to patients’concerns.1 A concern

frequently voiced by patients whoare consenting for a surgical proce-dure is prevention of postoperativenausea and vomiting (PONV), whichare distressing and dreaded.2,3 Nau-sea and vomiting after surgeryreportedly occur in approximately75 million patients annually,4 mak-ing these 2 conditions the most com-mon postoperative complications.Furthermore, PONV can contributeto fluid and electrolyte imbalances,airway compromise, suture tension,esophageal tears, dehiscence, venous

Postoperative nausea and vomiting is a dreaded, uncomfortable, and unpleasantpatient experience that is also a factor contributing to adverse outcomes in postop-erative recovery. The key to management of this concern is to identify high-riskpatients and to develop a systematic method of assessment, intervention, and eval-uation within the perianesthesia care continuum. This discussion outlines the widerange of pharmacological and alternative therapies that are available in clinical prac-tice with a case study to illustrate incorporation of these interventions in criticallyill patients. (Critical Care Nurse. 2011;31[6]:36-45)

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(CTZ) in the floor of the fourth ven-tricle.9,10 Each aspect of stimulationof these neural centers can be linkedto processes that may occur in apatient when anesthesia is used forsurgical interventions.

The medulla can be directlystimulated by the pharyngeal, vagal,and midbrain afferent nerves andby the limbic system. The pharyn-geal or gag reflex can be stimulatedby mechanical irritations such asinsertion or removal of a nasogastrictube, a laryngeal mask airway, or anendotracheal tube during the peri-anesthesia period. Vagal stimulationcan also occur with intubation orsuctioning that irritates the carina.In addition, vagal afferent pathwayscan be stimulated by noxious sub-stances in the duodenum or stomachand by distention and contraction

of the gastroin-testinal tract.10

A change inintracranialpressure evokesmidbrain stim-ulation, whichis a factor inneurologicalprocedures.The limbic areathat processesemotions canbe activated bythe learnedresponse of

anticipatory vomiting. The CTZhas multiple receptor sites forchemical signaling and activation.The CTZ is not contained withinthe blood-brain barrier, rather it isin the postrema on the floor of thefourth ventricle.9,10 This anatomicalsite positions the CTZ to sort eme-togenic risk factors from either bloodor spinal fluid10 and then activatethe vomiting reflex. PONV recep-tors include dopamine type 2, sero-tonin type 3 (5-HT3), histaminetype 1, muscarinic cholinergic type1, and neurokinin type 1.11 Block-ing these neurotransmitters is thebasis of pharmacological interven-tions. The CTZ can also be triggeredby the vestibular nerve (cranial nerveVIII) when extremes in pressure,motion, or position are sensed4,9,10

(Figure 1).

The vomiting reflex initiates a3-part set of physiological responses.These responses are characterizedas preejection, ejection, and post-ejection. Preejection begins withacetylcholine activation of the vagusnerve.9,10 Vagal nerve stimulationproduces increased salivation,tachycardia, diaphoresis, and adecrease in gastric tone. Nausea iscommonly experienced in the pre-ejection phase. Ejection starts withabdominal and diaphragmatic con-traction, continues with reflux ofgastric contents into the esophagus,and finishes with propulsion of thegastric contents out the mouth. Theglottis closes to prevent pulmonaryaspiration. Postejection appears tobe the diminished sensation of nau-sea in the central nervous system.9-11

Nausea is a symptom associatedwith vomiting. Because it is a sub-jective sensation, nausea is consid-ered conscious cortical activity.However, the anatomical tracts andchemical mediators that triggernausea are more elusive than thosethat trigger vomiting.3,5 Odors,motion sickness, vestibular stimula-tion, and hormonal changes of preg-nancy are all risk factors for nausea.In clinical practice and research,nausea and vomiting are oftentreated as a single phenomenon.However, they are separate and dis-tinct entities that can occur eitherindependently or together. Nauseashould be evaluated independentlyof vomiting so that nausea can bemore clearly delineated.12 Nausea inpostoperative patients may havedifferent risk factors than it does inother patients (eg, pregnant patients,patients with motion sickness). Areliable instrument for determiningthe risk factors for nausea has not

Angela Smith Collins is a clinical professor at the Capstone College of Nursing, Universityof Alabama, Tuscaloosa, Alabama. She works as a surgical critical care clinical specialistin the surgical intensive care unit at Baptist Princeton, an AACN Beacon Unit 2010-2011.In this position, her scholarly contributions are patient focused and linked to clinical outcomes.

Author

Corresponding author: Angela Smith Collins, RN, DSN, ACNS BC, CCNS, 504 University Blvd, Capstone College ofNursing, Tuscaloosa, AL 35487 (e-mail: [email protected]).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

www.ccnonline.org CriticalCareNurse Vol 31, No. 6, DECEMBER 2011 37

Table 1 Predictors of postoperative vomitinga

Risk level

High

Moderate

Indeterminate

Predictor

Being femaleHistory of postoperative nausea and vomitingHistory of motion sicknessPostoperative administration of opioidsUse of volatile anestheticsUse of nitrous oxideHistory of gastroparesisUse of birth control pillsPregnancy

Age (children)Duration of surgery

Type of surgery

a Based on information from Drain and Odom-Forren,4 Apfel et al,6 AmericanSociety of PeriAnesthesia Nurses PONV/PDNV Strategic Work Team,7 and Gan.8




been validated. The most commonmethod of measuring nausea is asimple 1 to 10 visual analogue scale.4,7,9

Operative/Anesthetic Risk Factors

Numerous risk factors are associ-ated with PONV. The 6 most commonfactors are surgical manipulations oforgans, use of inhalation agents, useof opioids, hydration, body position-ing, and release of cytokines.4,6-8

Surgical movement of organs byinstrumentation, insufflations, andmanual pressure disrupt the entero -chromaffin cells that line themucosa of the gastrointestinal tract.This disruption promotes the releaseof serotonin and stimulates theparasympathetic nervous systemvia the vagus nerve.10 Abdominaland gynecological surgeries areoften associated with increasedpostoperative emesis.4,6 These types

of surgery are often done laparo-scopically, and insufflation is usedto aid in surgical visualization andinstrumentation. Brain and spinalsurgeries have a high incidence ofemetogenesis.4,13 Neufeld and Newburn-Cook5 completed a sys-tematic review of the neurosurgeryresearch literature and found thatthe reported incidence of nauseaand vomiting in 13 studies washigh enough to warrant prophy-laxis in neurosurgery cases as agroup. Flynn and Nemergut13

reported that postoperative vomit-ing increased in endonasal transphe-noidal surgery when cerebral spinalfluid dynamics were affected by anintraoperative lumbar drain or fatgrafts for spinal fluid leaks.

Nausea and vomiting are a com-monly listed adverse effect of med-ications. The 4 medication classesfrequently associated with PONVare inhalation agents, opioids, anti-cancer medications, and estrogenpreparations.4,7,8,14,15 Inhalationagents are especially known as atrigger of PONV.7,8,15-17 Inhalationagents decrease the level of con-sciousness by decreasing the actionpotential amplitude and frequencyof the central nervous system. Thisdisruption of normal neural electri-cal output can stimulate the CTZand vomiting center.4 Comparedwith regional anesthesia, generalanesthesia is associated with an11-fold increase in risk for PONV.17

Opioids such as morphine orhydromorphone activate the CTZdirectly. Additionally, opioids bindto the µ and k opioid receptors inthe brain, spinal column, andperipheral nerves. Opioids activatethe µ2 receptor sites in the parasym-pathetic nervous system, a situation


Figure 1 Anatomy of emesis and variables that start the process.

Image by Rebecca Edwards.

Causative factors:Surgical and anesthesia interventions;pharyngeal, vagal, midbrain afferent

nerves and the limbic systemCausative factors:

Sensory input (pain, smell, sight);memory, anticipation, fear

Causative factors:Surgical and anesthesia interventions; dopamine type 2, serotonin type 3,histamine type 1, muscarinic cholin-

ergic type 1, and neurokinin type 1

Causative factors:Extremes in pressure, motion, or position experienced by the vestibular nerve

Causative factors:Surgical manipulation of organs,inhalation agents, use of opioids,hydration, positioning, and

cytokine release

Chemoreceptor trigger zone(Area prostrema of the

fourth ventricle)

Ear

Higher cortical centersVomiting center

(medulla oblongata)

Vomitingreflex

Small intestines

Stomach




that delays gastric and intestinalmotility. This activation leads to theadverse effects of nausea, vomiting,and constipation.15,16 Opioids alsotrigger the release of serotonin fromthe enterochromaffin cells in thegastrointestinal tract.9,10

Relative hypovolemia and dehy-dration associated with preoperativefasting, mandatory bowel prepara-tion, and blood loss also contributeto PONV.18,19 Induction of anesthesiain which systolic pressures decrease35% is associated with a higher inci-dence of PONV than is induction inwhich systolic pressures decreaseless.17 Preliminary reports19,20 ofmore aggressive preoperative hydra-tion suggest that this interventioncan diminish PONV, but the mech-anism by which the reduction occursis unclear.

During long surgical procedures,patients are unable to repositionthemselves because of anesthesiaand neuromuscular blockade. Thelack of movement can lead to bloodpooling and sensations of dizzinessthat can stimulate vestibular dis-equilibrium. This disequilibriummay lead to further activation of theCTZ by the vestibular nerve, actingas an additional trigger of PONV.4,7,18

Cytokines, immunoregulatoryglycoproteins, are released afterbarotrauma and other types of cel-lular damage. Cytokines trigger therelease of tachykinins such as sub-stance P.10 Substance P, a neuropep-tide, is important in sensorytransmission in both pain and nau-sea. The concentration of receptorsfor this neuropeptide (neurokinintype 1) is high in the medulla vomit-ing center. Activation of the receptorsappears to be a part of the commonpathway to regulate vomiting.21

Substance P also increases the dis-charge of salvia and histamine.Conversely, substance P decreasesthe release of bile and insulin.

Patient-Specific Risk FactorsTwo additional variables that

affect a patient’s risk for PONV arebeing female and being a nonsmoker.Compared with males, females havea lower threshold for vomiting thatis noted after puberty. Females vomit2 to 3 times more often than domales of the same age.22 Nausea andvomiting also occur more often withpregnancy and use of birth controlpills. These changes are attributedto the different endocrine mecha-nisms associated with child bearing.Nonsmokers metabolize anestheticagents more slowly than do theirsmoking counterparts. Smokingblocks liver enzymes involved inthe metabolism and excretion ofanesthetics.18,22

Interventions and GuidelinesASPAN has published evidence-

based guidelines7 that provide 2different algorithms as a practicalplan of care for patients at risk forPONV. The first algorithm (Figure 2)is used when surgery is elective andtime is too short to obtain a historythat will allow for risk stratificationfor the patient. The level of riskdetermines the choice of prophylac-tic pharmacological interventionsthat may diminish the occurrenceof PONV.

The second algorithm (Figure 3)can be used when preoperativeassessment is truncated because ofthe need for immediate surgicalintervention to save the patient’s life.This algorithm emphasizes earlyassessment and tracking of PONV

and the importance of rescueantiemetic therapy. Many tasksmust be completed when a patientwho has had lifesaving surgery istransferred to the intensive careunit by the operating room nurseand anesthesia care provider. How-ever, an important question duringthis transfer is what risk factorsdoes the patient have for PONVand what antiemetic prophylaxishas been implemented. Every timethe patient is assessed for pain, heor she should also be assessed fornausea and vomiting.

Antiemetic TherapiesEach acute care institution makes

mutidisciplinary decisions on whichantiemetic therapies will be chosenfor practice. These decisions aremade based on cost, preference,past adverse effects with the prod-uct, the effects of PONV on patients’outcomes, and current evidence.However, an aspect that should beincluded in the equation is the pref-erence of the patient and the patient’sfamily. The effectiveness of any inter-vention for PONV varies becauseeach patient has different absorp-tion, distribution, metabolism, andexcretion of anesthetic agents. Thesedifferences in pharmacokinetics aredue to genetic factors, sex, weight,and concurrent diseases.4,15 Evidencesupports use of pharmacologicalmethods, aromatherapy, herbal mate-rials, and acupuncture in PONV.18

If the surgery is elective, the healthcare provider can discuss the risksand benefits associated with eachantiemetic agent or method. Find-ing the medication or therapy thatis just right for a patient requireslistening to the patient: what hasworked in the past, what are his or





her preferences for alternative thera-pies, and what adverse effects ofinterventions has he or she experi-enced in the past?

Timing of the administration ofantiemetic therapies is also important.Medications such as ondansetron,an antagonist of serotonin (5-HT3)receptors, are most effective whenthe dose is given at the end of sur-gery.23 Corticosteroids such as dex-amethasone have greater efficacywhen given at the induction of anes-thesia.15,16 However, corticosteroids

should be contraindicated in patients,such as those with diabetes, whomay have problems with woundhealing. If opioids are indicated andhave been a problem in the past,then postoperative administrationof methylnaltrexone may be helpfulin blocking the unwanted adversegastrointestinal effects.24 Transder-mal scopolamine should be applied4 to 12 hours before surgery foroptimal effect.23

Aromatherapy with essential oilsand acupuncture are most efficacious

when used both before surgery andin the postoperative period.19,25 Aro-matherapy with inhaled isopropylalcohol is used to diminish olfac-tory input in the CTZ in the post-operative area.26 Cannabis-derivedmedications have not shown effi-cacy in PONV.27

In 16 clinical trials used in thesystematic review for the CochraneCollaboration,28 the effect ofacupuncture on nausea was stud-ied. The trials varied in methodsused. Statistical analysis of data


Figure 2 Algorithm 1: preoperative management of patients.

Abbreviations: NSAIDS, nonsteroidal anti-inflammatory drugs; PONV, postoperative nausea and vomiting.Reprinted from American Society of PeriAnesthesia Nurses PONV/PDNV Strategic Work Team,7 with permission from Elsevier (© 2006).

Preoperative Patient Management

Patient is at Low Risk for PONV

No prophylactic treatment necessary

Patient is at Risk for PONV

Determine the level of prophylactic treatment needed for patient:

Level of Risk Low Risk Moderate Risk Severe Risk Very Severe Risk

% chance of PONV 10 -20% 40% 60% 80%

# prophylactic interventions to

consider0 1 2 3 or more

Increased risk of surgical complication risk related to POV would move the patient up at least one risk factor level &indicate the need for additional interventions. Examples include, but are not limited to: maxillomandibular fixation,plastic surgery, intracranial surgery, etc.

- Identify patient risk factors using Risk Assessment Tool- Document & communicate patient risk factors to Anesthesiology & rest of surgical team

Anesthesia ConsiderationsTotal Intravenous AnesthesiaRegional Blocks NSAIDS

Other ConsiderationsImprove hydration

Multi-modal pain managementP6 acupoint stimulation

Pharmacological ConsiderationsDexamethasone

5-HT3 receptor antagonistsH1 receptor blockersScopolamine patch

Droperidol (consider black box warning)

Consider Prophylaxis for PONV




from these trials indicated that P6stimulation reduced the risk of nau-sea (relative risk, 0.72; 95% confi-dence interval, 0.59 to 0.89).28 Thenausea response was found to beseparate from the vomiting response.Acupuncture appears to diminishboth nausea and vomiting.28 In the40 research studies reviewed by theCochrane Collaboration,28 each studyvaried in the type of acupressure

and the timing of the intervention.The executive summary ratedacupuncture as effective as pharma-cological treatment with antiemeticsin preventing PONV. Acupressurestimulation can be created by needleacupuncture, transcutaneous electri-cal stimulus, acupressure by manualpressure, and acupuncture stimula-tion devices such as wristbands.The effect of invasive stimulation of

acupressure point P6 (Figure 4) onPONV outcomes did not differ fromthe effect of noninvasive stimulation.

In a recent trial29 of acupuncturein cardiovascular surgery patients,the incidence of nausea was signifi-cantly lower in the group who received1 preoperative acupuncture treat-ment than in the control group. Theacupuncture treatment occurred 0.5to 3 hours before surgery, and the


Figure 3 Algorithm 2: postoperative management of postoperative nausea and vomiting in phase I and phase II postanesthesiacare units.

Abbreviations: PACU, postanesthesia care unit; PONV, postoperative nausea and vomiting; VAS, visual analogue scale; VDS, verbal descriptive scale.Reprinted from American Society of PeriAnesthesia Nurses PONV/PDNV Strategic Work Team,7 with permission from Elsevier (© 2006).

Postoperative Management of PONV: Phase I PACU/Phase II PACU

Did patient receive prophylactic anti-emetic agent(s)?

Verify adequate hydration Aromatherapy Select & administer appropriate rescue anti-emetic5-HT receptor antagonistH1 Receptor Blockers

Droperidol (consider black box warning)

Late considerations may include:Low dose promethazine

ProchlorperazineMetoclopramide

Assess for PONV on admission, discharge & more frequently as needed

YES

If nausea is present, quantify severity using a VDS or VAS

YESNO

Implement Rescue Interventions

NO

Continue to monitor

Nausea/vomiting?

Select & administer appropriate rescue anti-emeticthat impacts a different receptor site than the prophylactic agent




acupuncture patients reported lesspostoperative nausea on day 1 andday 2 than the control patients did.

Prophylaxis TherapiesThe interventions for PONV

prophylaxis supported by publishedevidence are linked to using differentinstruments to measure a patient’srisk for PONV. No risk assessmentinstrument has been universallyaccepted and validated. The elementscommon to published instrumentsare the inclusion of the risk factorslisted in Table 1.

Of note, many experts cautionthat not all patients should receiveprophylaxis for PONV, because in apatient with low risk, the benefits donot outweigh the potential adverseeffects of the intervention.23 Addi-tionally, the anesthesia provider willdeliberate with the surgeon to deter-mine if the surgery can be completedwith a regional block of the site if thepatient has a history of severe PONV.ASPAN guidelines7 recommend 1prophylactic treatment for patientsat moderate risk, 2 for patients atsevere risk, and 3 for patients at verysevere risk. Recommended medica-tion classes are corticosteroids, sero-tonin (5-HT3) receptor blockers,histamine1 receptor blockers, and

scopolamine patches.7,15,23 Otherinterventions that may be helpfulare preoperative hydration, aggres-sive fluid replacement for blood loss,stimulation of acupuncture point P6,music therapy, and aromatherapy.18

Analysis of data30,31 on the efficacyof intraoperative supplemental oxy-gen in the prevention of PONV hasbeen conflicting, and this interven-tion currently is not recommended.

Intraoperative treatments thatcan also be helpful are decreasedblood pressure variability duringinduction, decreased use of neostig-mine, avoidance of nitrous oxide,and minimization of intraoperativeopioids.17,19,23 Ginger is an herbalalternative therapy used to preventnausea; however, many anesthesiaproviders and surgeons think the useof ginger is contraindicated becauseof the increased risk of bleeding andhyperglycemia.32

Rescue TherapiesBreakthrough PONV or new

development of PONV requires adetailed bedside assessment. Thepurpose of the assessment is to iden-tify a possible medication or mechan-ical trigger, such as an obstructionin the nasogastric tube or adminis-tration of a dose of a postoperativeantibiotic shortly before the occur-rence of the PONV. If no trigger canbe determined, then a rescue anti -emetic therapy should be started.The American Society of Anesthesi-ologists consensus guidelines23 rec-ommend 5-HT3 receptor antagonistsas the agents of first choice. If thismedication class has been used forprophylaxis, then a medicationfrom a different class should beused. A primary concern is control-ling any possible environmental risk

factors (eg, movement for radi-ographs, odors, dehydration, reposi-tioning, dangling, first sips ofliquids, and administration of opi-oids) to diminish the cycle of PONV.

For a comprehensive summaryof antimetic therapies for prophylaxisand rescue, see Table 2.

MonitoringMonitoring patients assists in

making decisions that are based onboth objective and subjective data.Severity of nausea should be quanti-fied by asking the patient to rate thenausea from 1 to 10 on a visual ana-logue scale. Nausea or vomitinginterventions should be reassessedat the peak time of the pharmaco-logical or nonpharmacologicalintervention. The volume, color,and contents of vomitus can beadditional data for determininghydration interventions and place-ment of decompression devices.

Case StudyMs Y, a 23-year-old woman, fell

asleep while driving home from thenight shift at the hotel where shewas night manager. Her compact carcollided with a large passenger vanat an estimated speed of 50 mph(80.5 km/h). Ms Y arrived in thelevel I emergency department within10 minutes of removal from herdeformed car. Her hemodynamicstatus was unstable, and she wasunconscious upon arrival at the hos-pital. Ms Y was restrained in hervehicle, but the van intruded into thedriver’s compartment. Ms Y sustaineda skull fracture of the left basilararea, left xyphoid bone, lacrimalbone, and supraorbital bone, with apenetrating injury of the left eye.She had a pseudo-aneurysm of the


Figure 4 Acupuncture point for reliefof nausea.

P6 acupuncture point iswidth of three of patient’sfingers from wrist.Acupuncturists call this the Neiguan point.





Table 2 Antiemetic medications, herbals, aromatherapy, and acupuncture used for prophylaxis and rescue

Medication

PhenothiazinesPromethazineProchlorperazine

AntihistaminesDimenhydrinateHydroxyzineMeclizine

Prokinetic agents Metoclopramide

5-HT3 serotonin receptorantagonists DolasetronGranisetronOndansetronPalonestron

Substance P/neurokinin type1 receptor antagonistAprepitantFosaprepitant

Dronabinol Marinol

Anticholinergic Scopolamine

CorticosteroidsDexamethasoneMethylprednisolone

Methylnaltrexone

Ginger Herbal

Comments relevant to medicationadministration

Increased incidence of adverse effects inelderly patients (eg, delirium), increasedintraocular pressure

Intra-arterial administration may causesevere tissue necrosis

Administer diluted in 10 mL of normalsaline: 25 mg intravenous in 10-15 min16

When used for motion sickness, administer1-2 hours before event

Dilute dimenhydrinate to 5 mg/mL andinject in several minutes16

Give doses slowly in 2-3 minutesGiven to patients with gastroesophagealreflux disease

Contraindicated in patients with history ofseizures or Parkinson disease16

Contraindicated in patients with history ofmigraines

Recommended administration beforeinduction of anesthesia or before reversal16

Used as an adjunct with corticosteroid and5-HT antagonist

Administer in 15 minutesIncompatibility with calcium in lactatedRinger solution

Use with pimozide (medication for Tourettesyndrome) can trigger life-threateningadverse cardiovascular reactions16

Use cautiously with patients with historyof substance abuse

Stimulates appetiteIncreased risk of adverse effects whenadministered with sedative, hypnotics,and psychoactive drugs15,16,27

Contraindicated in patients with angle-closure glaucoma, hyperthyroidism

Patch applied before surgeryWhen given intravenously, should be dilutedwith sterile water and given in 2-3 min16

Contraindicated in patients with activeuntreated infections

Delays wound healingIncreases insulin resistance16

Contraindicated in patients with known orsuspected mechanical gastrointestinalobstruction16

Increased risk of bleeding particularly withanticoagulant therapy

Potentiates antiplatelet, thrombolytic, andantidiabetic agents16,32

Mechanism of action

Decrease uptake of dopamine inthe CNS cause sedation15

H1 receptor sites in the CNS areblocked, causes adverse effectsof systemic anticholinergicaction15

Increases gastrointestinal motil-ity and rate of gastric emptyingby promoting the release ofacetylcholine in the gastroin-testinal tract15

Prevent activation of the CTZ byemetogenic drugs or stimuli15

Prevents substance P from activating the neurokinin type 1 receptors15

May inhibit endorphins in theemetic center, suppressprostaglandin synthesis,and/or inhibit medullary activ-ity through unspecified corticalaction15

Blocks receptor sites in theCNS, causing adverse effectsof systemic anticholinergicaction15

Reduces anticipatory nauseaand vomiting but decreasesinput to the cerebral cortex15

Blocks opioids receptor sites inthe gastrointestinal tract15

Prevents activation of the CTZby emetogenic drugs or stimuli32

Neurotransmitterblocked, relevance topostoperative nausea

and vomiting

Dopamine receptor sitesin the central nervoussystem (CNS)

Blocking acetylcholinein the CNS

Antagonizes the actionof dopamine, promotesperipheral release ofacetylcholine

Antagonists to sero-tonin receptors in thechemoreceptor triggerzone (CTZ)

Blocks the neurokinintype 1 receptors in the medulla vomitingcenter

Activates cannabinoidreceptors and blocksactivation of vomitingcenter

Targets acetylcholinereceptors activated byvestibular input to CTZ

Block prostaglandinsactivity in the cerebralcortex

Blocks peripheral opioidsreceptor sites

Antiserotonin-3 effectson the CNS and gas-trointestinal system

Continued




thoracic aorta at the level of the isthmus descending downward andstopping at the level of the diaphragm.Additional compound fractures ofthe left femur and pelvis were notedon computed tomography. Herblood pressure was sustained byadministration of 20 units of bloodproducts and crystalloids transfusedvia a rapid infuser. With minimaltime for history, she was takendirectly to the operating room.

A history was obtained from MsY’s mother by a member of the oper-ative team 20 minutes into the case.According to her mother, Ms Y hadno known medication allergies, wasa nonsmoker, had a history of motionsickness, had no concurrent diseases,

had previously had surgery for repairof the anterior cruciate ligament ofthe right knee, and was taking birthcontrol pills and a selective serotoninreuptake inhibitor for menstrualmood changes. It was not known ifshe had eaten before driving awayfrom work. Ms Y’s risk factors forPONV were head trauma, hypov-olemia, being female, being a non-smoker, a history of motion sickness,and use of birth control pills. With6 risk factors, she was considered atvery high risk for PONV. Triple ther-apy consisted of a 5-HTc antagonist(dolasetron), a corticosteroid (dex-amethasone), and a phenothiazine(prochlorperazine). Ms Y’s surgeryrequired 6 hours, with staged repairof the injuries; she was intubated,and general anesthesia was required.Open reduction internal fixationwas used to treat the fracture of theleft femur, and control of bleedingwas achieved when the femoralartery was repaired. The aortic

pseudoaneurysm was repaired viaa right femoral approach with anendovascular graft. The left eye wasremoved, and the eyelid wassutured shut. Because Ms Y hadsustained a basilar skull fracture, nonasogastric tube was placed.

Ms Y was brought directly fromthe operating room to the surgicalintensive care unit. Her carerequired coordination of manyhealth care providers. The teamleaders were the surgical residentand the anesthesiology residentwho were on call that day in theunit. The 4 main concerns for thefirst 4 days were keeping the cere-bral perfusion pressure optimized,preventing aspiration, preservingthe left lower extremity, and pre-venting multiple organ system dys-function. All of these concernscould be compromised if PONVwas not controlled. At 12 hoursafter surgery, Ms Y opened her eyesand tried to turn to the right. She


To learn more about postanesthesia care inthe critical care setting, read “PostoperativeDelirium After Colorectal Surgery in OlderPatients” by Thomson et al in the AmericanJournal of Critical Care, 2011;20(1):45-55.Available at www.ajcconline.org.

Table 2 Continued

Medication

Quease (aromatherapy)Essential oils of pepper-mint, ginger, lavender, and spearmint in a patented blend

Inhaled isopropyl alcoholAromatherapy

Acupuncture stimulation ofthe wrist point P6: invasiveand noninvasive

Comments relevant to medicationadministration

Contraindicated in patients with allergy topeppermint, ginger, or lavender

Skin rashes and irritation may occur16,25

Contraindicated in patients with allergy toalcohol-based products

Skin rashes and irritation may occur16,26

Patients’ reports of headache, bruising ofwrist, uncomfortable wrist bands, tired-ness and sleepiness during electro-acupuncture stimulation

Mechanism of action

Simple olfaction Aroma of the blend sends achemical message to the olfac-tory bulb where the impulsesare processed and passedalong to the limbic system inthe brain25

Simple olfactionAroma sends a chemical messageto the olfactory bulb where theimpulses are processed andpassed along to the limbicsystem in the brain26

Cochrane Collaboration summa-rizes that P6 acupressureseems to reduce the risk ofboth nausea and vomiting28

Neurotransmitterblocked, relevance topostoperative nausea

and vomiting

Antiserotonin-3 effectsof inhalation of oilsthrough cranial nerve I

Antiserotonin-3 effectsof inhalation of oilsthrough cranial nerve I

Unknown




vomited up 400 mL of green bile.Her heart rate decreased to 50/minbecause of the vagal stimulation.The rescue interventions were appli-cation of a scopolamine patch andrepeat doses of dolasetron every 8hours for the next 48 hours. Aspira-tion was prevented, and additionalepisodes of PONV did not occur.Before any mobilization and changesof position, aromatherapy was usedto diminish possible risk factors thatmight cause nausea and vomiting.

Ms Y’s injuries required addi-tional plastic surgery and fitting fora prosthetic eye. She spent a totalof 7 weeks in the critical care unit.Before her discharge, staff membersin the unit signed a large card tocelebrate her overcoming multipleinjuries that almost cost her her life.Ms Y’s comment to her providerswas thanks for relieving the worstheadache and nausea and vomitingof her life.

ConclusionPONV is an important concern

of patients, and effective manage-ment can improve patients’ out-comes and comfort. Finding theright intervention requires a discus-sion with the patient and the patient’sfamily about unique risk factorsand preferences and communica-tion between the providers of careacross the perianesthesia contin-uum. When health care choices arebased on the concerns of patientsand patients’ families, synergy pro-motes optimal outcomes. CCN

Financial DisclosuresNone reported.

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Angela Smith CollinsPostoperative Nausea and Vomiting in Adults: Implications for Critical Care

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Postoperative Nausea and Vomiting in Adults: Implications for Critical Care