Preventing PONV in High-Risk Patients

Many patients are more afraid of post-op nausea and vomiting (PONV) than they are of the surgery itself. That means a single incident of PONV can wreak havoc on your patient satisfaction scores and even prevent patients from scheduling critical surgeries in the future. Luckily, if you identify whether a patient is at a greater risk for this complication well before their procedure, you have plenty of options — including antiemetics, acupressure, aromatherapy and low-flow anesthesia — to prevent it.

PONV prevention starts with patient screening (see “How to Spot Potential PONV Cases”). If you’re not looking for risk factors, you’re not going to find any. On the other hand, you can learn a lot during the initial pre-op interview. Patients don’t want to feel sick after surgery and tend to be honest about their history of nausea and vomiting. If you simply ask, they will usually reveal what you need to know to assess their risks for PONV. If they’ve had surgeries in the past, they’ll be more likely to tell you about went wrong instead of all the things that went right. So, if they’ve ever experienced PONV, they’ll let you know.

If you have access to the patient’s electronic health record, check their health history to see if they’ve had past issues with PONV. Many areas now have Health Information Exchanges where all the hospitals in the area share access to the records of any patient who has visited one of the area’s facilities (unless the patient specifically opts out).

During the screening process, remember to not only ask about prescription medications but also about any supplements patients take. Reason: Some herbal supplements such as valerian, kava and chamomile can amplify the effects and side effects of narcotics, placing patients at a potentially higher risk for PONV.

For my doctoral dissertation, I focused specifically the importance of screening for PONV in pediatric patients. Children are twice as likely to experience PONV as adults, so this is an issue of critical importance. Pediatric PONV is also more likely to lead to overnight admission, which is both costly to the facility and upsetting for children and families.

In our facility, we found that we were not routinely screening for PONV history in pediatric patients. In response, we created a PONV history tab in the preanesthetic data forms, and put a “hard stop” in the forms so that the screening provider couldn’t go on to the next screen without taking a PONV history. Then we reviewed the charts of patients who had surgery two months before and two months after we implemented this change. We discovered that we were able to reduce rates of PONV by 22% with this simple, low-cost intervention. It also reinforced the importance of preoperative screening.

PONV prevention starts with patient screening (see “How to Spot Potential PONV Cases”). If you’re not looking for risk factors, you’re not going to find any. On the other hand, you can learn a lot during the initial pre-op interview. Patients don’t want to feel sick after surgery and tend to be honest about their history of nausea and vomiting. If you simply ask, they will usually reveal what you need to know to assess their risks for PONV. If they’ve had surgeries in the past, they’ll be more likely to tell you about went wrong instead of all the things that went right. So, if they’ve ever experienced PONV, they’ll let you know.

If you have access to the patient’s electronic health record, check their health history to see if they’ve had past issues with PONV. Many areas now have Health Information Exchanges where all the hospitals in the area share access to the records of any patient who has visited one of the area’s facilities (unless the patient specifically opts out).

During the screening process, remember to not only ask about prescription medications but also about any supplements patients take. Reason: Some herbal supplements such as valerian, kava and chamomile can amplify the effects and side effects of narcotics, placing patients at a potentially higher risk for PONV.

For my doctoral dissertation, I focused specifically the importance of screening for PONV in pediatric patients. Children are twice as likely to experience PONV as adults, so this is an issue of critical importance. Pediatric PONV is also more likely to lead to overnight admission, which is both costly to the facility and upsetting for children and families.

In our facility, we found that we were not routinely screening for PONV history in pediatric patients. In response, we created a PONV history tab in the preanesthetic data forms, and put a “hard stop” in the forms so that the screening provider couldn’t go on to the next screen without taking a PONV history. Then we reviewed the charts of patients who had surgery two months before and two months after we implemented this change. We discovered that we were able to reduce rates of PONV by 22% with this simple, low-cost intervention. It also reinforced the importance of preoperative screening.