Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2020
ReviewThe next generation of antiemetics for the management of postoperative nausea and vomiting.
Postoperative nausea and vomiting (PONV) afflict approximately 30% of patients overall and up to 80% of high-risk patients after surgery. Optimal pharmacological prophylaxis of PONV is challenging as it necessitates the consideration of PONV risk, drug efficacy, and potential adverse effects. ⋯ Newer antiemetics have been introduced that may have improved safety profiles, longer duration of action, and better efficacy. This review aims to summarize the recent developments pertaining to these new agents and their potential application toward the management of PONV.
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Best Pract Res Clin Anaesthesiol · Dec 2020
ReviewManagement of postoperative nausea and vomiting in the context of an Enhanced Recovery after Surgery program.
The concept of Enhanced Recovery after Surgery (ERAS) emerged at the turn of the millennium and quickly gained footing worldwide leading to the establishment of institutional ERAS protocols and subspecialty guidelines. While the use of postoperative nausea and vomiting (PONV) prophylaxis predates ERAS by a significant extent, the emergence of ERAS amplified the importance of antiemetic prophylaxis in perioperative care and drew attention to the truly multifactorial nature of postoperative gastrointestinal dysfunction. The following discussion will review key paradigms behind PONV prophylaxis and ERAS, highlight the interrelationship between these two endeavors, and then explore subspecialty ERAS guidelines that uniquely influence PONV prophylaxis. Attention will center on the ERAS Society guidelines (ESGs) as the primary representative of current ERAS practice, though many deviations from the guidelines exist within the literature and institutional practices.
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Best Pract Res Clin Anaesthesiol · Dec 2020
ReviewIs there a place for genetics in the management of PONV?
Antiemetic prophylaxis for postoperative nausea and vomiting (PONV) - a frequent complication in the postoperative period - is routinely given to high-risk patients. However, standard PONV risk models do not account for genetic factors, which have been shown to have a significant influence on PONV incidence and drug response. In this review, we describe the polymorphisms of various genes (serotonin, dopamine, cholinergic, etc.) and how pharmacogenomics is involved in the pathophysiology of PONV. This review also addresses how genetics is involved in today's clinical practice related to PONV and how it will change in the upcoming years as personalized medicine advances.
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Best Pract Res Clin Anaesthesiol · Dec 2020
ReviewRisk-adapted strategy or universal multimodal approach for PONV prophylaxis?
The issue of postoperative nausea and vomiting (PONV) remains important in surgical practice, contributing to patient distress, slower recovery, and increased use of healthcare resources. Many surgical patients report it to be a worse problem than pain. Numerous findings of research indicate that PONV significantly affects patients' well-being and is among the important determinants of patient satisfaction with perioperative care. ⋯ Thus, perhaps the biggest challenge across the field is to achieve a uniformly high standard of PONV management using the currently available resources. Although a risk-adapted approach has been advocated in the past, the current trend incorporated in clinical guidelines support a more liberal approach of multimodal antiemetic prevention. The current article emphasizes pros and cons of the various approaches to PONV prophylaxis and depicts most promising strategies to achieve a "PONV-free hospital."
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Best Pract Res Clin Anaesthesiol · Dec 2020
ReviewThe optimum management of nausea and vomiting during and after cesarean delivery.
Intraoperative and postoperative nausea and vomiting (IONV and PONV) afflict up to 80% of parturients undergoing cesarean delivery with neuraxial anesthesia. Preventing nausea and emesis is a top priority for women undergoing cesarean delivery and is included in the quality of recovery measures and enhanced recovery after cesarean delivery protocols. The majority of known perioperative emetic triggers can be avoided or mitigated by optimizing anesthetic and surgical management. ⋯ Furthermore, uterine exteriorization and peritoneal irrigation increase IONV risk. Conversely, preventing PONV mainly focuses on optimizing analgesia through an opioid-sparing, multimodal strategy. In addition, combination prophylactic antiemetic therapy should be instituted in this high-risk population to further reduce the risk of IONV and PONV.