Perioperative Multimodal Postoperative Nausea and Vomiting Prevention Strategies in the Ambulatory Surgical Setting

Abstract

Background/Purpose: Surgery employs a multitude of risks, one of which is postoperative nausea and vomiting (PONV). There are three factors that influence post-op symptoms: patient factors, anesthetic technique, and surgical related causes. The New Millennium Surgery Center (NMSC) located in Southfield, Michigan described an ongoing issue of PONV with patients undergoing Endoscopic Brow Lift and Herniated Orbital Fat Removal surgeries. The purpose of this Doctor of Nursing Practice (DNP) project was to identify potential anesthetic causes of PONV and post-discharge nausea and vomiting (PDNV) by doing a retrospective chart review at the New Millennium Surgery Center. Following the review, and in combination with the literature review findings, recommendations to aid in decreasing the incidence of PONV and PDNV at the surgery center were developed. Method: A systematic search of current literature was conducted. Inclusion criteria consisted of peer reviewed articles containing data on PONV rates in ambulatory surgery in both male and female patients and possible treatments for prevention. Articles from 2012-2023 that related to the prevention of PONV were included, while the articles related to these surgeries and plastic surgery complications dated back from 2002-2018. A retrospective chart review was then conducted and included 100 total combined cases of endoscopic brow lift and herniated orbital fat removal procedures conducted by Dr. Evan Black at the New Millennium Surgery Center from May 2021 to July 2022. Data was analyzed and recommendations were constructed based on the results of this data and literature review findings. Results: The data collected allowed three different drugs to be tested for significance with the Wilcoxon ranked sum. Opioids were not included related to findings which were not significant for PONV and PDNV. Results suggest Propofol did not influence observations of PONV (W = 400.50, p = .65). Ketamine was found to influence PONV (W = 4252.50, p = .05). Results suggested IV fluid did not influence PONV (W = 418.50, p = .73). Discussion/Conclusion: Statistical analysis of results from the retrospective chart review allowed for the development of recommendations for NMSC anesthesia providers and staff. Recommendations included reducing Ketamine dosing: 0.2mg/kg to 0.5mg/kg, adding Dexmedetomidine into the anesthetic technique for those patients that fit the administration criteria, and appropriately assessing NPO status to determine how much fluid a patient should receive throughout the perioperative period. Appropriately assessing NPO status was added to the recommendations based on literature review findings and one outlier found in the retrospective chart review.