The “big little problem”

The estimated incidence of postoperative nausea and vomiting (PONV) in the general surgical population ranges from 20% to 30% and up to 70% to 80% in high-risk patients. This adds significantly to the healthcare burden in terms of cost (extended hospital stay) and patient morbidity (prolonged disability). In fact, many patients rank PONV as the most distressing aspect of their hospital stay, reporting that PONV is a greater concern than postoperative pain. A recent survey found that patients are even willing to incur increased personal medical costs in an effort to reduce or prevent PONV.

PONV is an important, but often disregarded, complication of the patient’s surgical experience. Plastic surgery procedures have the highest incidence of PONV (Table 4.1). In fact, breast augmentation has a reported 8–10× higher incidence of PONV than other plastic surgery cases, with 42% immediate PONV and 43% incidence 24 hours after surgery. The ramifications range from physical (increased blood pressure potentiating postoperative bleeding, ecchymosis and edema) to psychological (unpleasant and uncomfortable experience for the patient). PONV is an often preventable cause of unanticipated hospital admissions, which leads to increased labor and material costs and disruption of patient flow through an already overburdened healthcare system. As the rate of elective outpatient procedures continues to grow, any effective effort to reduce or prevent unanticipated costs is certainly valuable.

Table 4.1 Type of surgery as a risk factor for PONV. Plastic surgery has the highest odds ratio for PONV

Risk factors for PONV

Targeted prevention of PONV

• Assessing patient risk factors (Table 4.2)

– patient characteristics

– type of anesthesia

– type and length of surgery (Table 4.1 and Fig. 4.1)

• Risk factor reduction

• Aggressive prophylaxis/combination treatment (Fig. 4.2)

– moderate-risk adults: 1 to 2 interventions

– high-risk adults: 2 or more interventions

– children: combination therapy

• Salvage treatment if prophylaxis fails.

Table 4.2 PONV risk factors

Patient-specific	Anesthetic-related	Surgically-related
Age Female Non-smoker History of PONV History of motion sickness Young age Migraine	Volatile anesthetics Nitrous oxide Intraoperative opioids Postoperative opioids	Duration of surgery Type of surgery

Factors separated by patient-specific, anesthesia-related, and surgery-related.

Fig. 4.1 Duration of surgery as a risk factor for PONV. As the duration of surgery increases up to 3 hours, the risk of PONV increases.

Fig. 4.2 Patient management algorithm for PONV. Single or multiple interventions are used depending on risk factors.

Prophylactic treatment

Nausea and subsequent vomiting are controlled by two centers in the brain, the chemoreceptor trigger zone (CTZ) and the emetic center (EC). The CTZ is located in the area postrema and has five different receptors which lead to activation. These receptors also serve as targets for anti-emetic medications. Neuronal pathways connect the CTZ to the EC, which is located in the reticular formation. The EC is activated through these neural pathways from the CTZ or directly by the vagus nerve resulting from gastric distension.

Known risk factors are the primary indication for PONV prophylaxis. As the number of risk factors increases, the risk of PONV increases. In fact, a patient with no risk factors has a PONV risk of 10%, while one risk factor gives a 20% risk. For each additional risk factor, the risk of PONV increases by 20% (Fig. 4.3).

Fig. 4.3 Compounding risk factors for PONV. The risk of PONV is directly proportional to the number of risk factors.

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