In and out the same day might sound nice to patients undergoing ambulatory surgery. But it may put them at a risk of post-discharge nausea and vomiting (PDNV) and post-operative cognitive dysfunction (POCD). Tuesday’s session “A 30-minute Anesthetic with a 30-day Impact” will detail those risks as well as the incidence of chronic post-surgical pain (CPSP) and solutions for both.

Girish P. Joshi, M.D., B.S., M.B., FCAI

University of Texas Southwestern Medical Center Professor of Anesthesiology and Pain Management Girish P. Joshi, M.D., B.S., M.B., FCAI, is among the panelists at the session. According to Dr. Joshi, ambulatory surgery patients are at risk because they no longer have access to intravenous antiemetics and may be unable to tolerate oral medication. The overall incidence of PDNV is 20% to 30%, with nausea ranking highest in 20% to 40% of cases, and vomiting occurring 10% to 30% of the time. Certain populations are at higher risk for PDNV, he said, including women over the age of 50, those with a history of PDNV, nausea in the PACU and the use of opioids in the PACU. Such high incidence is multifactorial, including inadequate use of antiemetic prophylaxis, use of high opioid dose intraoperatively and high opioid use after discharge home.

“Despite improved knowledge about risk factors and antiemetic strategies, none of the available algorithms completely prevents PONV and PDNV and none is universally applicable,” Dr. Joshi said.

A pragmatic fixed approach may be more successful, he said. Every patient, regardless of their presumed risk, must receive at least two antiemetics. Patients at very high risk of PONV/PDNV should receive three antiemetics. However, there are no benefits of using more than three antiemetics for prophylaxis. Pharmacological options for prevention of PONV/PDNV include dexamethasone, administered after induction of anesthesia, and a 5-HT3 antagonist (e.g., ondansetron given at the end of surgery). Patients with very high risk of PONV may receive transdermal scopolamine, if there are no contraindications. Dr. Joshi also discussed the management of PONV and PDNV, which includes use of an antiemetic from a different class, such as low-dose promethazine.

Treatment of PDNV includes ondansetron ODT, meclizine, prochlorperazine and dimenhydrinate. Non-pharmacological options include chewing gum, which is not inferior to ondansetron for the treatment of PDNV.

Above all, it is critical that patients receive minimal opioid doses, which means they should receive non-opioid analgesics such as acetaminophen and NSAIDs, and local/regional analgesic techniques.

“The lesson here is that the use of a minimum of two antiemetic prophylaxis for everyone will reduce PDNV,” Dr. Joshi said. “Additionally, reduce perioperative opioid use, and consider post-discharge, over-the-counter medicines, chewing gum and ondansetron ODT.”

The session also will explore the incidence of CPSP after various common operations. Statistics rank incidence of CPSP at 10% to 50%. Neurocognitive defects may persist as long as a year after surgery.