PONV

[urge]

What is your standard cocktaIl? Timing of drugs? Dose?

What's your cocktail for patients with prior PONV?

Are you following the SAMBA guidelines?

I do ondansetron 4mg, only towards the end. If prior PONV, or high risk, I toss dexamethasone 4mg at the end also. If patients still have PONV in pacu I add another dose of ondansetron 4mg, benadryl 50mg and metoclopramide 10mg.

I'm not precisely following the SAMBA guidelines but seems to work.

We don't have any of the newer antiemetics.

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[agammaglobulin]

I follow SAMBA guidelines and give nearly every patient 8-10mg Dexmethasone before incision (0.1-0.15mg/kg) and 4mg Zofran within 30 minutes of procedure end. Zofran and Dex are the most effective combination therapy per SAMBA. I would do Zofran, Dex, Droperidol (most effective triple therapy) but my hospital does not have Drop. High-risk PONV patients I do this and add TIVA or simply prop gtt last 1hr of the case and minimize narcotic use. Persistent PONV in PACU I add a third SEPARATE agent I have not given before from a different class, most often Phenergan or Haldol. Still has PONV? prop bolus or low dose prop gtt in PACU (not evidence based but seems to take them out of the PONV cycle...)

 

[sigrhoillusion]

My hospital has Emend which I never used as a resident but if they actually have a good history of PONV I'll order it pre-op. I had a lady the other day who said she vomited all night after her intitial ankle ORIF a few days prior. So I gave her Emend in pre-op, Decadron on induction and Zofran at the end. Saw her the next day and she had no nausea and was very happy. Not sure the cost of Emend, but if it makes the patient happy afterwards I'm fine with it, and it's academics and we love spending money... Also, not sure of the exact timing you need for Emend but I believe it's "within" 3 hours of induction. Not sure if the benefits are best 3 hrs prior, 1 hr prior, 10 minutes... But usually if it's not the first case of the day and the next patient is in holding, it gives them a good hour sometimes to digest it.

Also, if possible going with a regional or TIVA is helpful. We don't have droperidol (or Phenergan for that matter) and scop patch needs to be placed too early to be any benefit when I see them 15 minutes before the surgery.

The hospital also has several drugs on our PONV rescue list. I usually go with Compazine since I don't like double dipping on Zofran which has shown to be ineffective. They have Haldol 1mg and Tigan which I've used with success as like a 3rd line agent. They also have metoclopramide but haven't had to go with that. Yet... But usually I can get away with good old fashioned Zofran and Decadron and only rarely get called by the PACU.

 

[RxBoy]

The single best treatment for PONV is avoidance/reduction of IV narcotics. Give oral multimodal upfront and iv multimodal on the back end. Teach your PACU nurses to reach for orals instead of dilaudid.

All else fails, 1 mg IV haldol works wonders assuming you have givin dex/zofran

 

[pgg]

I would do Zofran, Dex, Droperidol (most effective triple therapy) but my hospital does not have Drop.

Haldol is an excellent replacement for droperidol.

 

[Shimmy8]

Don't expect PONV : zofran

Increased risk factors: +Decadron 4mg

h/o PONV: +scop patch from our pretesting/ +1.25mg haldol/Reglan/maybe TIVA depending on how bad hx and patient

 

[psychbender]

I give 4mg dexamethasone to nearly everyone pre/co- induction, usually 4mg ondansetron 30 minutes prior to emergence. I also try to minimize opiates however I can. In patients at increased risk of PONV or with a strong history, I'll usually do a TIVA or add promethazine or haloperidol to the end of the case or PACU meds.

 

[dhb]

I used to give dexamethasone to everyone but we had a shortage a couple of years ago and i noticed no difference in incidence of PONV so i stopped using it routinely.
Number one intervention regional + low to no narcs.
Hunch of small risk --> zofran
History of PONV --> zofran + drop or dex or both
Strong history: multiple ocurrences despite treatment --> tiva + the above

 

[deleted162650]

My hospital has Emend which I never used as a resident but if they actually have a good history of PONV I'll order it pre-op. I had a lady the other day who said she vomited all night after her intitial ankle ORIF a few days prior. So I gave her Emend in pre-op, Decadron on induction and Zofran at the end. Saw her the next day and she had no nausea and was very happy. Not sure the cost of Emend, but if it makes the patient happy afterwards I'm fine with it, and it's academics and we love spending money... Also, not sure of the exact timing you need for Emend but I believe it's "within" 3 hours of induction. Not sure if the benefits are best 3 hrs prior, 1 hr prior, 10 minutes... But usually if it's not the first case of the day and the next patient is in holding, it gives them a good hour sometimes to digest it.

Also, if possible going with a regional or TIVA is helpful. We don't have droperidol (or Phenergan for that matter) and scop patch needs to be placed too early to be any benefit when I see them 15 minutes before the surgery.

The hospital also has several drugs on our PONV rescue list. I usually go with Compazine since I don't like double dipping on Zofran which has shown to be ineffective. They have Haldol 1mg and Tigan which I've used with success as like a 3rd line agent. They also have metoclopramide but haven't had to go with that. Yet... But usually I can get away with good old fashioned Zofran and Decadron and only rarely get called by the PACU.

Careful with the Compazine. Relatively high incidence of dysphoric "freak out" reactions with that stuff.

My recipe is pretty much the same as what everyone else has said. I do think 6.25mg of Phenergan works great as a rescue in PACU without leaving 'em gorked.

 

[Noyac]

Likewise here.
The only thing I would add is if you have a pt in PACU that has PONV try a little propofol (20mg). It almost always makes them better.
It better than continuing to give them haldol, comparing, zofran etc. These drugs I view as preventative. Propofol is for when they are nauseated.

 

[PainDrain]

If no hx of ponv then ondansetron, give it to pretty much everyone. If mild ponv hx then I add dexamthasone and/or metoclopromide. If severe hx then I add a scope patch and Benadryl. Also have done TIVA with avoidance of large amounts of narcs for people with hx of severe ponv.

 

[Shimmy8]

Worst I've ever seen was a lady who had a minor procedure, first time ever getting GA. Forgot to tell us about her history of vertigo. Literally dry heaving and retching in PACU for hours post op. Only thing that worked was 20-30mg propofol every 30 min or so. Felt so bad for her, was awful. But the prop worked!

 

[sigrhoillusion]

for those with really bad hx of PONV and you guys run a TIVA. What are you usually doing for your TIVA? Just super-high doses of propofol? Ketamine? Precedex? Intermittent opioid boluses or infusions? (which theoretically increases risk of N/V?)

 

[deleted682700]

Meclizine 25 mg works very well. One of the old surgeons uses scopalamine patch on all his gall bladders.

 

[Noyac]

for those with really bad hx of PONV and you guys run a TIVA. What are you usually doing for your TIVA? Just super-high doses of propofol? Ketamine? Precedex? Intermittent opioid boluses or infusions? (which theoretically increases risk of N/V?)

Just plain propofol. Nothing special.

 

[Noyac]

And another trick for you youngsters.
I always save some propofol for the end of the case. About 5 min before I wake the pt up I give 30-50mg, whatever I have left.

 

[propadope]

Midazolam is an antiemetic too. I have used it on patients that were still nauseous after the usual suspects were given.

 

[deleted162650]

Midazolam is an antiemetic too. I have used it on patients that were still nauseous after the usual suspects were given.

At least they won't remember being nauseous.

 

[propadope]

At least they won't remember being nauseous.

Or won't remember that they weren't nauseous. Either way its a win!

 

[Mman]

Everybody gets Zofran.
If high risk they also get Pepcid + Decadron in preop. If hx motion sickness they get Scopolamine patch. If they are the person that pukes no matter what they get a regional technique or TIVA.

 

[pjl]

Everybody gets Zofran.
If high risk they also get Pepcid + Decadron in preop. If hx motion sickness they get Scopolamine patch. If they are the person that pukes no matter what they get a regional technique or TIVA.

Same, but probably a little less pepcid. I'm a bit quicker to play the propofol TIVA card than some.
Post op they get compazine or phenergan. Wish we had droperidol still.


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[Mman]

I'm a bit quicker to play the propofol TIVA card than some.

Propofol TIVA is a great anesthetic for the pukers. It's really hard to get much nausea if you combine that with minimizing narcotics.