Hepatic Failure/GI/Endocrine Emergencies
| d. | Neurokinin-1 receptor antagonists (e.g., aprepitant) should be given at the time of induction. Data |
|---|
are limited on the use of neurokinin-1 receptor antagonists in PONV; however, they appear to be
as effective as ondansetron. One large randomized double-blind trial evaluated 805 abdominal
surgery patients who were randomly assigned to receive 40 mg of oral aprepitant, 125 mg of oral
aprepitant, or 4 mg of intravenous ondansetron. Although there was no difference in the primary
outcome of complete response (considered no vomiting or use of rescue therapy), aprepitant at both
doses did reduce the occurrence of vomiting compared with ondansetron.
Transdermal scopolamine can be applied the evening before surgery. When used with ondansetron,
adding scopolamine was associated with a 10% absolute reduction in the occurrence of PONV
within the first 24 hours postoperatively.
When rescue therapy is needed within the first 6 hours postoperatively, an antiemetic should be selected
from a therapeutic class different from the initial prophylactic drug. Repeat doses of the same drugs that
were used for initial prophylaxis can be tried if PONV occurs more than 6 hours after surgery.
be tried.
Patient Case
A 27-year-old woman presents for a total abdominal hysterectomy. She is a nonsmoker who has a significant
history of motion sickness. During the procedure, she is expected to receive general anesthesia with volatile
anesthetics. She will probably require high-dose opioids perioperatively. Given this patient’s risk of devel-
oping PONV, which would she best receive for prevention of PONV?
gery, dexamethasone 4 mg intravenously at the time of induction, and ondansetron 4 mg intravenously
at the end of surgery.
of induction and ondansetron 4 mg intravenously at the end of surgery.
induction and ondansetron 4 mg intravenously at the end of surgery.
surgery.
Bleeding that occurs in the esophagus, stomach, or duodenum
as high in males as in females and increases with age.
Accounts for 350,000 hospitalizations per year at an annual cost of $2.5 billion
UGIB is 4 times more common than lower GI bleeding, and the hospitalization rate is around 6-fold
higher.