opioids. For PDNV, having nausea in the PACU and being younger than
50 are additional risk factors.
Just as anesthesia providers are using multimodal approaches to
combat pain and minimize opioids, they should use a multimodal
approach to minimize PONV, says Dr. Cazier. "If someone comes in
and says they get extremely sick every time they have anesthesia, and
they've even been hospitalized an extra day or two because of it, you
want to provide a full-court press and be as aggressive as possible.
You want to avoid volatile anesthetics, you want to use TIVA, provide
at least 3 antiemetics, use a pain block if possible and encourage the
surgeon to inject local anesthetics if you can't do a block."
And for patients who may not have been considered high-risk, there
are numerous options if PONV rears its ugly head in the PACU. What
you don't want to do is succumb to the tendency to administer the
same drug again and again if it didn't work the first time. "People want
to say maybe more Zofran will do the trick," says Dr. Cazier. "But if
they've had an appropriate dose and they're still sick less than 6 hours
post-administration, you need to target some other receptor to deal
with the nausea."
At least 5 classes of drugs that target different receptors are typically
available, says Dr. Cazier, including antihistamines, anticholinergics, phe-
nothiazines, corticosteroids and butyrophenones. Those, he says, are in
addition to other drugs that are often part of a multimodal pain regimen,
but which also have antiemetic properties, such as alpha-2 agonists, dex-
amethasone and gabapentin. That overlap is a benefit, says Dr. Cazier:
"By taking care of pain without relying purely on opioids, you're also
probably going to deliver some anti-nausea medication."
Although anxiety isn't a risk factor, it, too, is important to address.
"Some patients are more anxious about post-op nausea and vomiting
than they are about post-op pain," says Dr. Cazier. "You want them to
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