A Nurse-Led Evidence-Based Practice Protocol to Reduce Postoperative Nausea and Vomiting in the Bariatric Surgery Patient.

PURPOSE: To create and implement a standard care bundle to reduce postoperative nausea and vomiting (PONV) in the bariatric surgery patient. DESIGN: Evidence-based quality improvement project. METHODS: A pre- and postintervention chart review identified high-risk indicators for PONV in patients with longer lengths of stay (LOS), which led to the development of targeted care bundle components. FINDINGS: A clinically significant difference was observed in predicted PONV for Apfel scores 3 and 4 in patients receiving the full bundle compared with those receiving a partial bundle. Decreased LOS after implementation of the antiemetic care bundle was found. Health care provider compliance with bundle administration was low (57%). CONCLUSIONS: Clinically significant PONV scores were low after implementation of the antiemetic bundle for high-risk patients. The nurse-led creation and implementation of an antiemetic care bundle may have contributed to decreased LOS, reduced PONV, and reduced provider variability in care management.

Pediatric Postoperative Nausea and Vomiting: Assessing the Impact of Evidence-Based Practice Change.

Postoperative nausea and vomiting (PONV) is an unpleasant complication following anesthesia and surgical procedures experienced by both adults and children. Compared with adults, children are 2 times more likely to experience PONV. Many studies have identified and independently validated risk factors associated with the development of PONV in the pediatric population. Chief among these are patient age greater than 3 years, surgical duration greater than 30 minutes, surgical type, and a history of PONV. The purpose of this evidence-based practice change was to investigate if preoperative documentation of a patient's PONV history will lower PONV rates postoperatively. A PONV history assessment tab was created to aid in the documentation of the patient's PONV history, and a retrospective chart review was conducted 2 months before and 2 months after the practice change. A total of 2,279 preintervention cases were compared with 2,006 postintervention cases. Rates of PONV dropped 22%, from 153 preintervention cases to 120 postintervention cases, demonstrating a significant (P = .0043) decrease in PONV rates following a patient's reported history of PONV. Documentation of a patient's PONV history preoperatively led to a decrease in postoperative rates of PONV.

Evidence-Based Antiemetic Decision Tool for Management of Postoperative Nausea and Vomiting in Patients at High Risk of QT Prolongation and Patients Receiving Neurotransmitter-Modulating Medications.

Anesthesia providers have a myriad of medication options when developing and implementing a plan for the management of postoperative nausea and vomiting (PONV). However, anesthetists must be aware of the potential side effects, complications, and interactions of those medications, especially when managing high-risk populations. Although guidelines exist for the management of PONV in the general population, an evidence-based antiemetic decision support tool has not been developed for patients at risk of prolonged QT interval or for patients who are routinely receiving neurotransmitter-modulating medications. Safe practice recommendations exist but are scattered throughout the literature. The goal of this project was to develop a tool for anesthetists that concentrates the evidence and provides practice guidelines in these 2 selected populations. The methods for developing this tool were to perform a thorough literature search to gather evidence-based guidelines, organize findings in a convenient easy-to-read format, and validate guidelines by consultation with an expert panel. The product is a quickly accessible clinical tool listing guidelines for 8 commonly used antiemetic agents to assist anesthetists in PONV management.

Prevention of Nausea and Vomiting After Laparoscopic Sleeve Gastrectomy: Are We Doing Enough?

The worldwide obesity epidemic has led to an increase in the number of bariatric procedures for treatment. Currently, the most commonly performed bariatric surgical operation in the United States is the laparoscopic sleeve gastrectomy (LSG). The risk of postoperative nausea and vomiting (PONV) is exceptionally high following the LSG: as much as 65%. Anesthesia providers should be mindful of this elevated risk and stay up to date on evidence-based techniques that help to mitigate the incidence of PONV related to this specific procedure. The purposes of this clinical review are to increase provider awareness of the PONV risk following LSG and to examine methods for improving PONV outcomes for this population.

Pharmacogenetics of Postoperative Nausea and Vomiting.

Postoperative nausea and vomiting (PONV) remains one of the most common adverse effects of anesthesia, affecting up to 80% of high-risk patients within 24 hours after surgery. Patient-related factors, surgical procedure, and perioperative medications such as opioids determine a patient's risk for PONV. To prevent and manage PONV, ondansetron, a 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist, is frequently administered. Ondansetron is metabolized predominantly by hepatic cytochrome P450 (CYP2D6) enzymes, encoded by the CYP2D6 gene, whereas most of the effects of opioids are exerted at the opioid mu-1 receptor, encoded by the OPRM1 gene. Genetic polymorphisms of the CYP2D6 and OPRM1 genes may have a role in interindividual variation in the occurrence of PONV. Specifically, the occurrence of the G-allele produced by the OPRM1 A118G appears to be protective against PONV, whereas CYP2D6 ultrarapid metabolism increases the risk for PONV. The Clinical Pharmacogenetics Implementation Consortium guidelines provide CYP2D6-guided therapeutic recommendations for ondansetron. However, further studies are needed to investigate the role of genetic polymorphism in the occurrence of PONV and response to antiemetics.

Patients' self-reported nausea: Validation of the Numerical Rating Scale and of a daily summary of repeated Numerical Rating Scale scores.

AIM AND OBJECTIVES: To validate the Numeric Rating Scale (NRS) for postoperative nausea assessments, and determine whether a central tendency, median, based on patients' self-rated nausea is a clinically applicable daily measure to describe patients' nausea after major surgery. BACKGROUND: Postoperative nausea causes major discomfort, risks for complications and prolonged hospital stays. The NRS is recommended for the assessment of pain but is little explored for assessing nausea. DESIGN: A repeated measure design was carried out on patients who had undergone major surgery in three Swedish hospitals. METHODS: Nonparametric statistical methods were used to analyse (a) associations between the NRS and a verbal scale (no, mild, moderate and severe) and (b) to analyse associations between Measure 1 (nausea scores postoperative Day 1) and Measure 2 (retrospective nausea scores at rest and during activity, postoperative Day 2). Reporting of this research adheres to the Strobe Guidelines. RESULTS: The mean age of the 479 patients (44% women) in the sample was 65 years (range, 22-93 years). Self-assessed nausea scores from the NRS and the verbal scale correlated well (rS pearman  = 0.79). Correlation between nausea at rest and nausea during activity was rS pearman  = 0.81. The calculated median scores (Measure 1) showed only moderate correlations with retrospective nausea scores (Measure 2); 4-9 ratings, rS pearman  = 0.41; 6-9 ratings, rS pearman  = 0.54. CONCLUSIONS: Numeric Rating Scale scores showed strong associations with a verbal scale; therefore, the NRS seems to be a valid tool to measure nausea intensity. The quality of daily summarised median nausea scores needs to be further explored before clinical use. RELEVANCE TO CLINICAL PRACTICE: The use of the NRS in assessments of nausea in postoperative care will facilitate communication between patients and health care professionals regarding nausea intensity. When documenting nausea, it seems unnecessary to distinguish nausea at rest from nausea during activity.

A Quality Improvement Project to Determine the Effect of Aromatherapy on Postoperative Nausea and Vomiting in a Short-Stay Surgical Population.

Postoperative nausea and vomiting (PONV) is a major concern for short-stay surgical patients because it can delay discharge and cause preventable postoperative complications, which in turn can increase hospital costs. Evidence suggests that aromatherapy effectively reduces PONV, either as a monotherapy or in conjunction with pharmacologic antiemetics. This quality improvement project investigated the effectiveness of aromatherapy in reducing PONV in a short-stay surgical population. The outcome of this project supported the hypothesis that the administration of blended aromatherapy would result in a significant decrease in patients' self-reported ratings of nausea. This finding suggests that aromatherapy is an appropriate adjunct therapy for decreasing patient nausea and vomiting in this short-stay surgical unit and may help prevent discharge delays in this population.

Reexamining Metoclopramide's Role in the Prevention of Postoperative Nausea and Vomiting: A Secondary Analysis.

Postoperative nausea and vomiting (PONV) continue to be among the most undesirable and distressing complications following general anesthesia, affecting 20% to 30% of all surgical patients and up to 70% of patients with multiple known risk factors. The purpose of this study was to reexamine the effectiveness of metoclopramide in the prevention of PONV when stratified by PONV risk scores. Secondary data from 2,116 adult ambulatory surgical patients were analyzed. Participants were, on average (SD), 49.7 (15.4) years of age, with a mean body mass index of 28.3 (6.9) kg/m², and were primarily female (65%). Risk scores for PONV ranged from 0 to 4, with a mean of 2.6 (1.0). Metoclopramide, 10 mg intravenously (IV) alone; metoclopramide, 10 mg IV, combined with ondansetron, 4 mg IV; and metoclopramide, 10 mg IV, combined with dexamethasone, 8 mg IV, and ondansetron, 4 mg IV, had a beneficial effect for adult ambulatory surgical patients with PONV risk scores of 1 to 4. Although this cohort study had limitations, future studies should investigate metoclopramide based on risk score recommendations, and guidelines should be reevaluated.

Reasons for delayed patient discharge following day surgery: a literature review.

Aim The aim of this literature review was to explore the reasons why some patients are not suitable for discharge following day surgery. Method A pragmatic, mixed-methods approach was used to undertake a critical evaluation of the literature and current practice to determine what is already known about discharge following day surgery. Thematic analysis was used to identify the main themes and issues, enabling recommendations to be made to reduce the incidence of patients unable to be discharged following day surgery. Findings The main themes or reasons for delayed discharge following day surgery identified from the literature review were: post-operative nausea and vomiting, post-operative pain, going late to theatre and social factors. These themes were supported by the findings of an unpublished audit carried out in one day surgery unit in an NHS healthcare organisation in the south of England between June and August 2014, which indicated that 54 out of 1,180 day surgery patients required an overnight stay during this 12-week period. The audit also showed that a patient going late to theatre had the greatest effect on discharge outcomes. Conclusion Recommendations for practice include: the introduction of post-operative nausea and vomiting risk scoring and prophylactic protocols; reorganisation of theatre lists to ensure patients have enough time to recover; and provision of information during the pre-assessment process about the requirement for a responsible adult escort to take patients home and stay with them for the first 24 hours. These changes may help NHS organisations to improve discharge outcomes for day surgery patients and reduce unplanned costs.

Reducing the Incidence of Postoperative Nausea and Vomiting Begins With Risk Screening: An Evaluation of the Evidence.

Postoperative nausea and vomiting (PONV) is a daily concern for patients and perianesthesia nurses. PONV is experienced by approximately one third of all surgical patients. Identification of patients at risk for PONV through preoperative risk assessment is an effective means in reducing the incidence of PONV. Perianesthesia nurses are positioned to implement such risk assessments by using simplified risk scores to identify moderate to high-risk patients. Risk assessment allows for facilitation of targeted prophylaxis which positively impacts the patients' surgical outcome and experience. Targeted prophylaxis is efficacious in reducing the institutional incidence of PONV which decreases resource utilization and cost. The perianesthesia nurse is the crucial component in minimizing the PONV in the post-surgical patient. This evaluation of the evidence reveals that preoperative PONV risk screening leads to decreased incidence of PONV for the surgical patient, improves patient satisfaction and reduces postoperative complications.

Psychometric Properties of the Ambulatory Surgery Index of Nausea, Vomiting, and Retching.

BACKGROUND AND PURPOSE: At least one-third of ambulatory surgery patients will experience nausea or vomiting during the recovery period. The purpose of this study was to examine the psychometric properties of the Ambulatory Surgery Index of Nausea, Vomiting, and Retching (AS-INVR). METHODS: Secondary analysis of longitudinal data from a study of 203 adult ambulatory surgery patients was conducted. RESULTS: Based on the results of factor analysis, the retching item was eliminated and the 6-item, 2-dimensional AS-INV was formed. Cronbach's alphas for the AS-INV ranged from .83 to .87 across the 5 days postsurgery. Higher AS-INV scores were associated with self-reported presence of nausea and lower quality of life. CONCLUSIONS: The shortened AS-INV provides a reliable and valid measure of the amount and distress because of nausea and vomiting in adult patients after ambulatory surgery and should be considered for use in future studies.

Utilization of a Preemptive, Multimodal Analgesic Regimen in Adult Ambulatory Septoplasty Patients: A Quality Improvement Project.

This paper describes a quality improvement project designed to decrease postoperative pain, decrease post-operative nausea and vomiting (PONV), decrease time in the recovery room, and increase patient satisfaction in adult ambulatory septoplasty patients using a multimodal, preemptive analgesic regimen. The project was conducted in a community hospital setting with nine operating rooms, and a twenty one bed recovery room. Project participants included certified registered nurse anesthetists, anesthesiologists, operating room nurses, recovery room nurses, and otolaryngology surgeons. Following a period of departmental education, adult patients scheduled for outpatient septoplasty surgery received a preoperative regimen of medications that included gabapentin, celecoxib, and acetaminophen. Using a pre-post test design, (intervention group n = 17, non-intervention group n = 17) data was collected from patient and analyzed using SPSS version 18.0. The change in practice resulted in a significant decrease in pain scores in the recovery room and on discharge from the recovery room. In addition, patients who received the preemptive regimen also required significantly fewer opioid medications and were ready to be discharged from the recovery room in less time.

[The effect of corticosteroids in children and adolescents after tonsillectomy in the prevention of postoperative nausea and vomiting, pain and bleeding]. / Kortikosteroide zur Prävention von postoperativer Ubelkeit und Erbrechen, Schmerzen und Blutungen bei Kindern und Jugendlichen nach Tonsillektomie.

Tonsillectomy and adenotomy are the most common pediatric surgical procedures, with approximately five millions performed each year worldwide (O'Mathúna, Wiffen & Conlon, 2010). However, this procedure is accompanied by significant postoperative morbidity, which may include postoperative pain, postoperative nausea and vomiting (PONV), poor oral intake with consequent dehydration and postoperative bleeding (Hanasono et al., 2004). If pain is not treated effectively, it can cause avoidance behaviors related to further healthcare. Inadequate pain management has been found to increase morbidity and mortality rates in postoperative patients of all ages (O'Mathúna, Wiffen & Conlon, 2010). In addition, there is an increase in the incidence of PONV: 40% in children with pain compared to 16% in children without pain. PONV also disturbs significantly the wellbeing and patient satisfaction, it can lead to a substantial prolongation of time in the recovery room with increased costs of personal care. In pediatric patients PONV is the most common cause of the approximately 1% to 2% of unplanned hospitalizations following outpatient surgery (Rüsch et al., 2010). The incidence of bleeding after tonsillectomy is approximately 0.5-10%, with deaths occurring in 1 in 20,000 patients (Kim et al., 2011). In recent years, several scientists have explored the effect ofcorticosteroids in the reduction of morbidity after tonsillectomy. In this publication, the question is addressed to what extent perioperatively administered corticosteroids can reduce pain, PONV and postoperative bleeding in the context of tonsillectomy in children and adolescents. For this purpose, a narrative literature analysis of the electronic databases and journals was conducted. There is evidence that corticosteroids can reduce postoperative morbidity. However, no evident and clear recommendation can be drawn from the advices of the various studies.

Association between serotonin transport polymorphisms and postdischarge nausea and vomiting in women following breast cancer surgery.

PURPOSE/OBJECTIVES: To examine the association of the serotonin transport gene and postdischarge nausea and vomiting (PDNV) in women following breast cancer surgery. DESIGN: A cross-sectional study. SETTING: A comprehensive cancer center in Pittsburgh, PA. SAMPLE: 80 post-menopausal women treated surgically for early-stage breast cancer. METHODS: Data were collected using standardized instruments after surgery but before the initiation of chemotherapy. Blood or saliva were used for DNA extraction and analyzed following standardized protocols. Data were analyzed using descriptive statistics and logistic regression. MAIN RESEARCH VARIABLES: Serotonin transport gene (SLC6A4), nausea, vomiting, pain, and anxiety. FINDINGS: Women who inherited the LA/LA genotypes were at greater risk for nausea and vomiting when compared to women who carried any other combination of genotypes. Twenty-one percent of women reported nausea and vomiting an average of one month following surgery and prior to initiation of adjuvant therapy. Those women who experienced PDNV reported significantly higher anxiety and pain scores. CONCLUSIONS: Findings of this study suggest that variability in the genotypes of the serotonin transport gene may help to explain the variability in PDNV in women following breast cancer surgery and why 20%-30% of patients do not respond to antiemetic medications. IMPLICATIONS FOR NURSING: Nurses need to be aware that women who do not experience postoperative nausea and vomiting following surgery for breast cancer continue to be at risk for PDNV long after they have been discharged from the hospital, and this frequently is accompanied by pain and anxiety.

Standardizing documentation for postoperative nausea and vomiting in the electronic health record.

Postoperative nausea and vomiting (PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Clinicians use the American Society of PeriAnesthesia Nurses (ASPAN) guideline to help prevent and treat PONV. However, the lack of standardized terminology in the electronic health record (EHR) and the lack of clinical decision support tools make it difficult for clinicians to document guideline implementation and to determine the effects of nursing care on PONV. To address this, we created a concept map of the Perioperative Nursing Data Set (PNDS) that illustrates the relationship between elements of this standardized nursing terminology and the ASPAN guideline, using the Systematized Nomenclature of Medicine-Clinical Terms multidisciplinary terminology to fill any gaps. This mapping results in a standardized dataset specific to PONV for use in an EHR, which links nursing care to nursing diagnoses, interventions, and outcomes. The mapping and documentation in the EHR also allows standardized data collection for research, evaluation, and benchmarking, which makes perioperative nursing care of patients who are at risk for or experiencing PONV measureable and visible. Distributing this information to perioperative and perianesthesia nursing personnel, in addition to implementing risk assessment tools for PONV and clinical support alerts in electronic documentation systems, will help support implementation of the PONV clinical practice guideline in the EHR.

Assessing the risk of post-operative nausea and vomiting.

Post-operative nausea and vomiting (PONV) is a common complication for many surgical patients, causing anxiety and distress. Evidence suggests that nursing practice in this area is inconsistent and that nurses' knowledge needs to improve, to promote better patient outcomes. This article provides a review of the incidence of PONV, associated complications and risk factors. Examples of risk assessment tools that could be used to identify patients at risk of developing PONV are described to ensure timely and appropriate treatment.

Preventing postoperative nausea and vomiting: refresh your knowledge of how to recognize and respond to this common complication.

For surgical patients, postoperative nausea and vomiting (PONV) is one of the most undesired complications of anesthesia and surgery.