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Postoperative Issues/What is a normal range for PONV?

QUESTION:

I am the Director of Nursing in a free standing surgery center. We had an increase of post-op nausea and vomiting (PONV). Calculated out there was 10% of the patients having postoperative PONV. It has since decreased to 6.25%. Are these numbers within normal range for PONV? We do general surgery, ENT, podiatry, and plastics.

-- From Cathy Smith, R.N., B.S.N.

REPLY:

The postoperative nausea and vomiting (PONV) rate in a free-standing surgery center will depend not only on the type of surgical procedure but on the anesthetic regimen and on a number of preoperative clinical risk factors. There are literally thousands of clinical studies in this area. From these studies among the most commonly cited factors that predict PONV are female gender, young age, previous history of PONV, and use of narcotics. A rate of 6.25 to 10% on the face of it does not appear excessive. Rates as high as 30% or more are noted in the literature for certain surgical procedure and high risk groups.

Another point worth noting is that PONV is not a binary outcome. Nausea, and vomiting, will vary in severity. Furthermore, antiemetic agents differ in their ability to prevent nausea, compared with prevention of vomiting. To define this more carefully, nausea and vomiting scores, similar to those used for the quantification of pain, are in use in some centers.

Although reduction of PONV is, because of its unpleasantness, a worthy objective for any outpatient surgery center, keep in mind that PONV is only an intermediary outcome. To assess whether your rate is inappropriately high, check whether PONV is itself leading to a significant number of unexpected admissions, delayed discharge from the facility, or patient dissatisfaction with perioperative care. If that is the case then it is probably worthwhile dissecting out the cause for a higher PONV rate and focusing on preventive and therapeutic measures. By applying multimodal interventions, including multiple antiemetic agents, adequate hydration, propofol-based anesthesia, avoidance of narcotic analgesics and nitrous oxide, the PONV rate can be reduced to very low levels (Scuderi. Anesthesiology 1999;90:360-371)

-- From Gary Kantor, M.D., Cleveland, OH

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