patient's pain can trigger PONV, so can we use a transverse abdominis
plane block or interscalene block to minimize the use of post-op opi-
oids?
4
Have a game-day game plan. Here's my day-of-surgery
approach to PONV prevention:
• Providing IV hydration early will help avoid dehydration. This
will prevent nausea, but it can also ensure that the patient gets back on
her feet quickly. As long as there's no contraindication, I'll give 20 mL
per kilo of an isotonic lactate solution like Ringer's or Plasma-Lyte.
Avoiding normal saline solution helps prevent hyperchloremic meta-
bolic acidosis.
• A scopolamine transdermal patch may be appropriate for anybody
who has a history of nausea and vomiting but who isn't prone toward
dementia, because it can cause post-operative confusion. Also, it
takes some time for the body to absorb the scopolamine, so it's not a
good option for procedures that last less than 2 or 3 hours.
• If a muscle relaxant is needed, I dose appropriately to minimize the
need for reversal, because neuromuscular blockade reversal agents
like neostigmine and glycopyrrolate are known to cause nausea.
• As long as there is no contraindication,
consider a multi-receptor approach using a number of antiemetic
interventions: aprepitant, which is a selective high-affinity antagonist
A P R I L 2 0 1 7 • O U T PA T I E N TS U R G E R Y. N E T • 4 5
pressure point, which is located about 3 finger widths below the
hand-wrist crease, in the depression between the tendons —
experienced 59% fewer instances of post-op nausea and nearly
91% fewer instances of post-op vomiting, compared with
patients who were given neither. — Bill Donahue
