Best practice & research. Clinical anaesthesiology
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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
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
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
Editorial ReviewNew insights into the pathophysiology and risk factors for PONV.
Postoperative nausea and vomiting (PONV) affects patient outcomes and satisfaction. New research has centered on evaluation of post-discharge and opioid-related nausea and vomiting. Mechanical and drug effects stimulate the release of central nervous system neurotransmitters acting at receptors in the vomiting center, area postrema, and nucleus of the solitary tract. ⋯ Pharmacogenetics plays a role in gene typing as antiemetic medication metabolism results in varying drug effectiveness. Risk scoring systems are available. Individualized multimodal plans can be designed as part of an enhanced recovery after surgery protocol.
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Best Pract Res Clin Anaesthesiol · Dec 2020
ReviewAn update on the management of PONV in a pediatric patient.
Postoperative nausea and vomiting (PONV) is a major cause of patient dissatisfaction following anesthesia. The difficulty in diagnosing nausea in much of the pediatric population has led to an emphasis on anti-emetic prophylaxis for all. ⋯ New antiemetics emerging from other medical disciplines, particularly oncology, may have potential use in prophylaxis and treatment of nausea and vomiting in the pediatric surgical population. New agents, many of which have a long duration of action, will augment the anesthesiologist's ability to adequately prevent PONV, and to treat persistent nausea and vomiting that extend beyond the immediate post-operative period.