Cola

Salvan

ANESTHESIOLOGY 260 SGD

Block Z 2018
Viloria
Yap, C.
Zamesa
Zapanta
GENERAL DATA
T.C
68 years old
Female
Single
Filipino
Iglesia Ni Cristo
Occupation?
CHIEF COMPLAINT
Abdominal heaviness
HPI
14 years PTA,
Noted abdominal heaviness for which whole abdominal ultrasound was done revealing ovarian new
growth
Advised transvaginal ultrasound : confirmed presence of ONG

Interim prior to recent consult

Noted gradual abdominal enlargement
No associated abdominal pain, vaginal bleeding, bladder or bowel symptoms

2 weeks PTA
Noted increasing abdominal heaviness, sought consult at OPD, and advised elective surgery
PRE-OPERATIVE DIAGNOSIS AND PROCEDURE
Ovarian New Growth, Probably Benign; Endometrial Polyp

Exploratory Laparotomy, Total Hysterectomy with Bilateral Salpingo-oophorectomy

POST-OPERATIVE DIAGNOSIS
Ovarian New Growth, right, probably serous cystadenoma;
Endometrial mass, probably endometrial polyp

s/p Exploratory Laparotomy, Total Hysterectomy with Bilateral Salpingo-

oophorectomy
PRE-OPERATIVE EVENTS
NPO
No antibiotics given
INTRAOPERATIVE EVENTS
BASELINE VITAL SIGNS
BP: 130/70 mmHg
HR: 65 bpm
RR: 16 cpm
T: afebrile
SpO2: 100%
Weight: 41 kg
Sensorium: Fully awake (GCS 15)
ANESTHESIA
Type: Regional (SAB)
Agents:
Bupivacaine Heavy 20 mg + Morphine Sulfate 0.2 mg + Epinephrine 0.2 mg

IV Medications:
Ephedrine 10 mg
Midazolam 1 mg x 4 doses
Propofol 200 mg
Ketorolac 30 mg
Paracetamol 900 mg

IV Fluid: PNSS D5NR

OPERATION
Total OR time: 2 hours
EBL: 150 cc
U.O: 100 cc
POST-OPERATIVE EVENTS
Analgesics
Nalbuphine 10 mg IV q2-6 hours for PS 3/10

Anti-emetic:
Ondansteron 4 mg IV for nausea/vomiting
POST-OPERATIVE EVENTS
1 hour post-op
BP documented at: 85-100/45-60
Intervention: PNSS 300 mL run for 15 minutes

2 hours post-op
Onset of nausea, 1 episode of vomiting, and multiple episodes of retching
PRIMARY WORKING IMPRESSION
Postoperative Nausea and Vomiting
DISCUSSION POSTOPERATIVE NAUSEA AND
VOMITING (PONV)
INTRODUCTION
Nausea and/or vomiting or retching in the PACU and in the immediate 24 postop hours
Common following general anesthesia
Nausea 50%
Vomiting 30%
May result to prolonged PACU stay
patient satisfaction
hospital cost
PATHOPHYSIOLOGY POSTOPERATIVE NAUSEA AND
VOMITING (PONV)
5 principle neurotransmitter
receptors
Muscarinic M1
Dopamine D2
Histamine H1
5-hydroxytryptamine (HT)-3 serotonin
Neurokinin (NK1) substance P

A. Central
B. Peripheral
C. Drugs/Toxins
RISK FACTORS POSTOPERATIVE NAUSEA AND
VOMITING (PONV)
RISK FACTORS
Patient Factors Anesthetic Factors Surgical Procedures
Preoperative nausea/vomiting Technique (GA) Cholecystectomy
Female gender Volatile anesthetics Gynecologic Procedures
History of PONV or motion sickness IV Laparoscopy
Nonsmoking NO Strabismus Surgery
Age Duration of anesthesia Adenotonsillectomy
Chemotherapy-induced Opioid
Neostigmine
RISK SCORING
TREATMENT POSTOPERATIVE NAUSEA AND
VOMITING (PONV)
PROPHYLAXIS Patient
Specific Risk Low, medium, or high

FACTORS TO CONSIDER

Wound disruption
Increase in ICP Consequences
Clot disruption post of Surgery
angiographic procedures

Preferences Patient and Clinician

Implications
for a change
in anesthetic
technique
ALL PATIENTS
v Multimodal and opioid-sparing pain control strategy.
v Reduction of pain has been correlated with a reduction in PONV.
vAdditional measures:
vModification of anesthetic technique
vAdiministration of antiemetics
vNonpharmacologic prophylactic measures
RISK REDUCTION
v Modification of anesthetic technique
vAdequate Hydration
vMeta-analysis of 15 randomized trials, approximately 1600 patients, liberal intraoperative crystalloid administration (15-20
mL/kg) reduced the risk of late and overall PONV but not early PONV compared with restrictive IV fluids (0-2 mL/kg)

vChoice of Fluid (dextrose containing versus non-dextrose containing

vPatients who received D% had less PONV within 24 hours of surgery.

v Multimodal approach to pain control

 HIGH RISK ADULTS
May include:
1. Scopolamine patch applied 2 hours
Regional Anesthesia may be pre induction, removal within 24
offered if appropriate for ANESTHETIC hours.
the procedure. If general
TECHNIQUE ANTIEMETICS 2. Dexamethasone 4 mg IV post
anesthesia is required, TIVA induction.
with propofol. 3. Ondansetron 4 mg IV at the end of
surgery.

Multimodal approach, may

include: If with episode of vomiting at the PACU,
1. Paracetamol 1g IV POST
administration of antiemetic of a
2. Ketorolac 15-30 mg IV OPERATIVE RESCUE different drug class such as:
3. Regional or local PAIN ANTIEMETICS 1. Prochlorperazine 5-10 mg IV
infiltration may be CONTROL 2. Droperidol 0.625 mg IV
offered
 MODERATE RISK ADULTS
May include:
1. Scopolamine patch applied 2 hours
Regional Anesthesia may be pre induction, removal within 24
offered if appropriate for ANESTHETIC hours.
the procedure. If general
TECHNIQUE ANTIEMETICS 2. Dexamethasone 4 mg IV post
anesthesia is required, TIVA induction.
with propofol. 3. Ondansetron 4 mg IV at the end of
surgery.

ADJUNCT
Acupuncture
LOW RISK ADULTS
vProphylaxis should be based on clinician and patient preferences,
formulary choices, and cost.
vUsual agent given: Ondansetron 4 mg IV at the end of surgery
for those receiving general inhalational anesthesia or TIVA that
includes opioids.
vGiven the drugs low side effect profile and cost.
vNo prophylaxis for those who receive TIVA with propofol without
opioids. Though some may opt to still administer.
MEDICATIONS
Ondansetron
Aprepitant
Dexamethasone
Droperidol
Meclizine
Metoclopramide
MEDICATIONS
Agent Class/MOA Dose Effects
Ondansetron 5-HT3 receptor 4 mg IV, given at end of Gold standard
antagonist surgery Anti-nausea and anti-
vomitingAprepitant
WOF: QTC prolongation
Aprepitant NK-1 receptor 80 mg PO Long half life
antagonist Greater anti-emetic effect than
ondansetron
Dexamethasone Corticosteroid 5-8 mg IV prophylactic Relative CI in labile diabetic
(post induction) patients
Decreases nausea, pain, fatigue
Droperidol Butyrophenones 0.625 to 1.25 mg IV Used in combination with
prophylactic, givena t end ondansetron
of surgery
MEDICATIONS

Meclizine Antihistamine 50 mg PO Used in combination with

ondansetron, longer
duration
Metoclopramide Dopamine antagonist, 25, 50 mg Increases upper GI
partial 5-HT4 motility and upper
antagonist gastroesophageal
sphincter tone, relaxes
pylorus and duodenum
to promote gastric
empyting
WOF: extrapyramidal
effects
NON-PHARMACOLOGIC PROPHYLAXIS
Should be considered as adjuncts to pharmacologic prophylaxis in patients at high risk
for PONV

P6 stimulation reduces nausea, vomiting,

and the need for rescue antiemetics
compared to Sham stimulation (placebo)
Efficacy similar to prophylactic antiemetics e.g.
ondansetron, droperidol, metoclopramide,
cyclizine, and prochlorperazine
No difference in effectiveness on adult vs
children, invasive vs non-invasive acupuncture
modalities
NON-PHARMACOLOGIC PROPHYLAXIS
Should be considered as adjuncts to pharmacologic prophylaxis in patients at high risk
for PONV

Fowler's or semi-Fowler's position for

nauseated patients
At least 1 g of ginger per os 1 hour before
induction is more effective than placebo in
preventing PONV
Adequate IV sedation is an effective
strategy in reducing the baseline risk for
PONV