Hepatic Failure/GI/Endocrine Emergencies

Patient Case

A 40-year-old man presents for a large bowel resection. Because of the complexity of the procedure and the

anticipated use of perioperative opioids and inhalation anesthesia, the team is creating a plan to prevent POI.

Which medication would be best to recommend for reducing the incidence of POI?

Postoperative vomiting occurs in about 30% of overall surgical patients, whereas postoperative nausea

occurs in about 50%. In high-risk patients, the incidence of PONV can be as high as 80%.

unplanned hospital admissions for outpatient procedures.

Surgical factors that increase the risk of PONV:

Use of volatile anesthetics: The effect of volatile anesthetics on PONV is usually dose-dependent

and typically presents within the first 6 hours postoperatively.

Use of postoperative opioids: The effect of postoperative opioids similarly increases the risk of

PONV in a dose-dependent fashion.

Use of general anesthesia

Type of surgery: Cholecystectomy, laparoscopic, gynecological are most commonly associated

with PONV.

Female sex

History of motion sickness, chemotherapy-induced nausea and vomiting, or PONV

Nonsmoker

The Apfel simplified risk score is based on four predictors: female sex, history of PONV and motion

sickness, nonsmoking status, and use of postoperative opioids. The estimated risk of PONV is 10%,

20%, 40%, 60%, and 80% when zero, one, two, three, or four of the above risk factors are present,

respectively.

A stratified prevention strategy is suggested according to the number of risk factors, as follows:

Low risk (zero risk factors): No pharmacologic prophylaxis recommended; a “wait and see”

strategy is suggested

Medium risk (one or two risk factors): One or two prophylactic interventions are recommended.

High risk (more than two risk factors): Three or more prophylactic interventions should be used.

administered to all patients regardless of risk factors because risk scores are not completely

predictive.