Postoperative nausea and vomiting (PONV)

 Pasien tuh suka PONV as worse than postoperative pain1

 PONV biasanya sembuh sendiri tapi kadang butuh hospital admission and delay recovery room
discharge23
 Mual muntah bias bikin wound dehiscence, sophageal rupture, aspiration, dehydration,
increased intracranial pressure, pneumothorax4
 PONV lebih dijelaskan sebagai mual muntah post anesthesia care unit (PACU) / 23 jam
postoperative.
 4 neurotransmitter receptor yang bikin nausea vomiting: muscarinic M1, dopamine D2,
histamine H1 5-hydroxytryptamine (HT)-3 serotonin, neurokinin (NK1) – substance P5.
 Pathophysiology :
1. Central mechanisms
Mual dan muntah di trigger oleh higher cortical centers yang berkomunikasi dengan
vomiting center dimedulla. Perioperative perios seperti fear, pain, anxiety bikin mual dan
stimulasi dari vestibular systmen merupakan central stimuli yang bikin nausea and vomiting
(kayak tympanoplasty, karena transmitted via H1 histamine and M1 acetylcholine receptors
yang bias bikin profound PONV6
2. Peripheral mechanisms
Gastric stimulation dasri gastric trauma, blood, toxins yang melepaskan substance P and
serotonin dari enterochromaffin cells yang ngengaktifik vagal and splanchnic nerve 5-HT3
receptors7.
Vagal and splanchnic nerve afferents itu berasal dari nucleus tractus solitaries di brain stem,
berada didekat atau within area postrema (atau disebut juga chemoreceptor trigger zone).
Bowel surgery dan darah yang masuk ke GIT entah dari operasi THT bias bikin nausea and
vomiting via this way.
3. Drugs and toxins
Anesthetic dan opioid bikin nausea itu complex and incompletely understood8
Opioid dan inhalation anesthetic bias bikin nausea vomiting karena stimulasi postrema yang
ada di base of fourth ventricle di medulla. Dimana postrema akan berkomunikasi vomiting
center via dopamine dan serotonin untuk trigger vomiting reflex9.
 Risk Factors:
1. Faktor risiko pasien
- Preoperative nausea and vomiting

1
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting/abstract/1
2
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting/abstract/2,3
3
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting/abstract/2,3
4
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting
5
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting/abstract/4
6
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting/abstract/5
7
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting/abstract/6
8
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting/abstract/7
9
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting/abstract/8,9
Postoperative nausea and vomiting (PONV)

Paling banyak terbukti tapi diabaikan, karena pake anestesi ( biasanya karena renal
colic).
- Female gender10,11
Karena dari penelitian diatas emang cewe itu predictor PONV (OR 2,57)
- History of PONV or motion sickness12,13,14
Bias meningkatkan risiko PONV di adults.
- Nonsmoking independent risk factor PONV (OR 1,82) 15
- Age16,
Menurunnya PONV in adults kalo umurnya makin tua.
- Chemotherapy-induced nausea vomiting17
-
2. Anesthetic factors
- Anesthetic technique
General anesthesia higher incidence mual muntah disbanding regional. Tapi regional
anesthesia akan menurunkan PONV dengan menurunkan dosis opioid untuk nyeri
pascaoeprasi.18
- Volatile anesthetics
Merupakan factor risiko PONV19,20,2122. Isoflurane, enflurane, sevoflurane higher risk of
PONV compared propofol 23
- IV anesthetics
Ketamine dan etomidate do not independently increase PONV dalam dosis yang
dianjurkan 24 untuk induksi anestesi. Low dose ketamine malah reduce PONV by
decreasing postoperative opioid requirements 25
- Nitrous oxide (N2O)
Meningkatkan risiko PONV disbanding no N2026
- Duration of anesthesia

10
https://www.ncbi.nlm.nih.gov/pubmed?term=23035051
11
https://www.ncbi.nlm.nih.gov/pubmed?term=10422935
12
https://www.ncbi.nlm.nih.gov/pubmed?term=9165963
13
https://www.ncbi.nlm.nih.gov/pubmed?term=23035051
14
https://www.ncbi.nlm.nih.gov/pubmed?term=10422935
15
https://www.ncbi.nlm.nih.gov/pubmed?term=9165963,
https://www.ncbi.nlm.nih.gov/pubmed?term=23035051, https://www.ncbi.nlm.nih.gov/pubmed?term=10422935
16
https://www.ncbi.nlm.nih.gov/pubmed?term=8267183,
https://www.ncbi.nlm.nih.gov/pubmed?term=23035051, https://www.ncbi.nlm.nih.gov/pubmed?term=22846680
17
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting/abstract/22
18
https://www.ncbi.nlm.nih.gov/pubmed?term=9165963
19
https://www.ncbi.nlm.nih.gov/pubmed?term=9165963
20
https://www.ncbi.nlm.nih.gov/pubmed?term=12067003
21
https://www.ncbi.nlm.nih.gov/pubmed?term=20151955
22
https://www.ncbi.nlm.nih.gov/pubmed?term=8777095
23
https://www.uptodate.com/contents/postoperative-nausea-and-vomiting/abstract/23
24
https://www.ncbi.nlm.nih.gov/pubmed?term=11050522
25
https://www.ncbi.nlm.nih.gov/pubmed?term=15271729
26
https://www.ncbi.nlm.nih.gov/pubmed?term=8777095
Postoperative nausea and vomiting (PONV)

Longer duration anesthesia with volatile anesthetic increase risk of PONV27. Karena
procedurenya lebih lama, tend require larger of postoperative opioids.
- Opioid administration
Karena studi berkata demikian28
3. Type of surgery
Studies of the effect of the type of surgery on the incidence of PONV have reported
conflicting results. The best evidence suggests that cholecystectomy, gynecologic,
and laparoscopic procedures are associated with modestly increased risk of PONV
compared with other general surgical procedures29

Risk score for postoperative nausea and vomiting for adults

The components of the simplified risk score include the following four highly predictive risk
factors:
●Female gender
●Nonsmoker
●History of motion sickness or previous PONV
●Expected administration of postoperative opioids
This risk score has been validated within and across institutions; the presence of 0, 1, 2, 3,
and 4 of these risk factors corresponds to risk of PONV of 10, 20, 40, 60, and 80 percent,
respectively 30

27
https://www.ncbi.nlm.nih.gov/pubmed?term=23035051,
https://www.ncbi.nlm.nih.gov/pubmed?term=10422935,
https://www.ncbi.nlm.nih.gov/pubmed?term=11883387, https://www.ncbi.nlm.nih.gov/pubmed?term=16861255
28
https://www.ncbi.nlm.nih.gov/pubmed?term=23035051,
https://www.ncbi.nlm.nih.gov/pubmed?term=9165963, https://www.ncbi.nlm.nih.gov/pubmed?term=10485781
29
https://www.ncbi.nlm.nih.gov/pubmed?term=23035051
30
https://www.ncbi.nlm.nih.gov/pubmed?term=10485781