Postoperative Nausea and Vomiting with Plastic Surgery: a Practical

Home , Ramosetron

- (Plast. 3 2,6,9,11 The consequences of nau- 4–7 The neurochemical mechanisms 2,8–10 Although there is a tendency to discount the Although there is a tendency to Symptoms occurring in the surgery recovery The authors have no financial interest The authors have no financial interest Disclosure: to the content of this article. in relation to declare See Committee Statement and Disclaimer at the end of this article. problem of PONV, it remains one of the most sig- it remains one of the most problem of PONV, postanes- nificant factors resulting in prolonged thesia care unit stay and hospitalization following ambulatory surgery. whereas area are commonly referred to as PONV, sea and vomiting can be severe and may contrib- incisional ute to complications such as hematoma, dehiscence, respiratory compromise, pain, longer and patient dis- slower recuperation, hospital stay, satisfaction. studies on the condition list incidences as high as studies on the condition list incidences found that the 56 percent, whereas a meta-analysis overall incidence was 28.3 percent. mediating the physiology of nausea and vomiting are presented in Figure 1. www.PRSJournal.com For many There are 1 2 Summary: where many aes- Ambulatory surgery common in plastic surgery, is performedbe can procedures reconstructive and thetic ambula- hospitals, in tory surgery centers, or office-based surgery facilities. Outpatient surgery offers accessibility, increasing by surgeon the and patient the both to advantages care. lowering cost; and maintaining high-quality and convenience; flexibility, and and comfort, postoperative nausea experience optimize a patient’s To who de- in those patients should be prevented. However, vomiting (PONV) it must be appropriately managed and treated. The incidence of velop PONV, to accurately predict those patients who PONV is variable. It is often difficult manifest symptoms. There are a variety of will develop PONV or how they will prophylaxis and treatments that are po- recommended “cocktails” for PONV the type of treatment given is often tentially effective. The decision regarding and determination of side-effect profile, more related to provider preference characteristics, because of the absence rather than targeted to specific patient For others. over practices specific support to data reliable of volumes large of tunately, there are several tenets for the successful prevention and treatment there are several tenets for the successful tunately, literature and summarize here. The fol- of PONV we have extracted from the a summarylowing is of current state of the surgeon plastic the practicing for risk factors, prophylaxis, and treatment the literature regarding PONV cause, servethat may practice management. study and for further as a guide Surg. 141: 214, 2018.) Reconstr. and Houston, Texas

Marta Zielinski, M.A.

ccording to government statistics, more statistics, government to ccording than 60 percent of surgical procedures performed in the United States annually

Debra J. Johnson, M.D. Debra J. Johnson, Karol A. Gutowski, M.D. Karol A. Gutowski,

Steven C. Bonawitz, M.D. Steven C. Bonawitz, Baltimore, Md.; Sacramento, Calif.; Baltimore, Chicago and Arlington Heights, Ill.; Robert W. Thomsen, M.D. Robert W. C. Bob Basu, M.D., M.P.H. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003924 From Johns Hopkins Plastic and Reconstructive Johns Surgery;From Sacramento Plastic and Reconstructive Surgery Medical Chicago Cosmetic Institute and University; Inc.; Group, The Johns Hopkins Outpatient Clinic; Houston Methodist Hospital; the American Society of Plastic Surgeons; The West Medicine; and the BasuUniversity School of Johns Hopkins Center for Aesthetics and Plastic Surgery. Received for publication November 9, 2015; accepted July 18, 2017.

Michele A. Manahan, M.D. Michele A. Manahan, SPECIAL TOPIC SPECIAL Warren A. Ellsworth IV, M.D. IV, A. Ellsworth Warren plastic surgery procedures, general inhalational narcotic pain control are required and anesthesia and may predispose patients to postoperative nau- was sea and vomiting (PONV). General anesthesia immedi- was PONV and 1840s, the in introduced ately found to be a common problem.

214 A Impact, and Treatment Impact, Plastic Surgery: A Practical Advisory to Etiology, to Etiology, Advisory A Practical Surgery: Plastic Postoperative Nausea and Vomiting with and Vomiting Nausea Postoperative varying estimates on the incidence of PONV, likely varying of PONV, estimates on the incidence resulting from diversity among patients, surgical procedures, and pharmaceuticals used. Reported are performed on an outpatient basis. Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. American Society of Plastic Surgeons. Copyright © 2017

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Fig. 1. Diagram indicating a response from the vomiting center. GI, gastrointestinal.

symptoms that develop following discharge from Table 1. Risk Factor Predictors the recovery are increasingly referred to as post- Patient-related predictors discharge nausea and vomiting. The precise Female sex definition of these terms, however, has not been Active smokers established. Postdischarge nausea and vomiting History of PONV/motion sickness Genetics is often included in the definition of PONV. It is Age (50 yr or younger) convenient to consider these as the same phenom- Obesity (BMI >30 kg/m2) enon defined by their time frame of occurrence, Anesthesia-related predictors Postoperative opioids although there is some evidence that there may be Inhalational anesthetics differences in the causative mechanisms. Postdis- Nitrous oxide charge nausea and vomiting has not been as well Surgery-related predictors 4,11,12 Surgery duration studied as PONV. Patients who experience Surgery type postdischarge nausea and vomiting do not neces- Other factors sarily experience PONV in the recovery area, and High patient anxiety the risk factors do not appear to be identical. There Postoperative pain is clearly a need for further research into postdis- BMI, body mass index. charge nausea and vomiting, and with time, this et al. are commonly used: female sex, history of may develop into a more distinct entity rather than motion sickness/PONV, nonsmoker, and use of existing under its current guise as refractory PONV. postoperative opioids. Other risk factors are also included in Table 1.16,17 RISK FACTORS FOR INCIDENCE None of the risk factors alone are able to Risk factors for PONV fall into four cat- predict PONV, yet they have a strong predictive egories: patient-related, anesthesia-related, accuracy. Plastic surgeons should identify those surgery-related, and other factors.13–15 The four patients at higher risk and discuss the possibility patient-related risk factors described by Apfel of PONV before any surgical procedure.

Pharmacologic interventions to alleviate the to minimize discomfort, either through local symptoms associated with PONV are summarized injection or the use of longer acting modalities in Table 2.11,18,19 There are a variety of recom- [e.g., liposomal bupivacaine (e.g., Exparel; Pacira mended “cocktails” for prophylaxis and treat- Pharmaceuticals, Inc., Parsippany, N.J.)], pain ments that are potentially effective. The decision pumps) can result in decreased postoperative nar- regarding the type of treatment given is often cotic need for pain control and be beneficial in more related to provider preference, rather than reducing opiate-induced PONV.21–25 targeted to specific patient profiles, because of Emphasis deserves to be placed on avoidance the absence of large volumes of reliable data to of situations that may produce nausea and vomit- support specific practices over others. As further ing. Well-recognized trends over time within plas- emphasis is placed on this field, risk stratification tic surgery support movement toward procedures systems and consensus guidelines are emerging. performed solely under local and/or regional The reader is encouraged to pursue the rapidly anesthesia whenever possible. These situations, changing literature in this area and use risk-strati- which may encompass significant operations not fication and/or treatment regimen tools as appro- only on the extremities but also the trunk, head, priate for individual practice.18 and neck, require no sedation and can obviate the need for the strategies compiled to reduce and Surgeon’s Role in Prevention/Prophylaxis treat PONV. In many practices, anesthesiologists will ulti- Careful questioning of the patient regarding mately choose PONV pharmacologic regimens. prior experience with postoperative pain medi- Surgeons, however, must actively participate in cation can provide information regarding previ- decreasing PONV and associated complications. ous side effects. Patients with a history of nausea Surgeons are often asked to allay patient fears pre- and vomiting with opioid medications may ben- operatively and will bear the brunt of dissatisfac- efit from use of other classes of analgesic medi- tion when PONV occurs. cations, such as nonsteroidal antiinflammatory Discussion of PONV must be part of the pre- drugs or acetaminophen. Patients requiring more operative consultation. Many plastic surgery vigorous pain control, but who are intolerant of patients harbor overly optimistic opinions regard- oxycodone, may benefit from the use of tapent- ing their postsurgical recovery. Providing specific adol (Nucynta; Depomed, Inc., Newark, Calif.)], counseling and education regarding risk factors a benzenoid class of opioid with improved gastro- for PONV and early education regarding modifi- intestinal tolerability.26 able risk factors may be beneficial. Patients with previous PONV successes or failures may benefit Anesthesiologist’s Role in Prevention/ from a review of prior anesthetic records, because Prophylaxis individuality of response is the rule rather than To control PONV, the surgeon and anesthe- the exception.20 siologist must work in concert. Stratification of On the day of surgery, patients should be risk factors (as discussed above) allows for iden- actively encouraged to be forthcoming about tification of those patients with a greater risk for PONV symptoms as they develop to allow early development of PONV. Many of the interventions treatment. Communication between the anesthe- may be joint ventures between the anesthesia and sia and surgical teams will facilitate comprehensive surgery teams. planning for perioperative prophylaxis. Maintain- General anesthesia using volatile agents ing adequate hydration and minimizing blood loss increases the risk of PONV. In patients who have are important. Risk factors identified by the sur- previously experienced PONV or have other geon may determine special circumstances to be risk factors, agents such as nitrous oxide, inhala- discussed with the anesthesiologist, which might tional agents, etomidate, and ketamine should alter routine planning for PONV prophylaxis.20 be avoided.6,13 Regional and local anesthesia can Minimizing the duration of surgery and pro- offer a lower risk of PONV and might be used as tecting the gastrointestinal tract from draining an adjunctive measure to general anesthesia.6,19 blood are important risk-reduction strategies.10,18,19 Total intravenous anesthesia with propofol infu- Performing procedures using only local anesthe- sion allows for anesthesia without the emetogenic sia will obviously protect the patient from expo- side effects of inhalational anesthetics. The anes- sure to emetogenic volatile anesthetics.18,19 Even thesia team must keep the patient adequately in those cases where general anesthesia or deep hydrated to avoid exacerbating the emetogenic sedation is necessary, the use of local anesthetics effects of inhalational agents.6

Notes warning effective than 5-HT3 antagonists* box ( droperidol) palonosetron superior for patient-controlled anesthesia use Generally less Avoid touching eyes Avoid FDA black Granisetron

Risks dry mouth, blurred vision, extrapyramidal, vascular necrosis (promethazine) dizziness arrhythmias (droperidol), arrhythmias sedation (ondansetron) Drowsiness, urinary retention, Visual disturbance, dry mouth, QT prolongation, ventricular Hyperglycemia (questionable) Headache, prolonged QT 9 3 3

20 10 40 1–4 3–4 7–17 8–12 6–8 4–9 6–7 3–5 9–13 14–37 Half-Life (hr)

Timing Every 4–6 hr Every 4–6 hr Anesthesia induction End of surgery 4 hr or more preoperatively End of surgery End of surgery End of surgery End of surgery Anesthesia induction End of surgery End of surgery End of surgery End of surgery End of surgery 1–2 hr preoperatively

Dose 1 mg/kg IV 25–50 mg IV 6.25–25 mg IV 25 mg IV

Transdermal patch 1.5 mg Transdermal

0.625–1.25 mg IV 10 mg IV 0.5–2 mg IM/IV 5–10 mg IM/IV

4 mg IV

4 mg IV 0.35–1.5 mg IV 2 mg IV

80 mg PO Prophylaxis and Treatment Options Treatment and Prophylaxis IV, intravenously; FDA, U.S. Food and Drug Administration; IM, intramuscularly; PO, orally. intravenously; FDA, U.S. Food and Drug Administration; IM, intramuscularly; PO, orally. IV, Table 2. Table Name H1-R antagonist* Dimenhydrinate Cyclizine Promethazine Diphenhydramine Muscarinic receptor antagonist Scopolamine Dopamine receptor antagonist Droperidol Metoclopramide Haloperidol Prochlorperazine Steroids Dexamethasone 5-HT3 antagonist* Ondansetron Granisetron Tropisetron Ramosetron Palonosetron NK1-R antagonist* Aprepitant

Personalized risk assessment will stratify using nonsteroidal agents such as ketorolac (Tor- patients into varying risk categories. Although adol; Roche, Basel, Switzerland) and cyclooxy- there is debate on the ideal prevention algo- genase-2 inhibitors [e.g., celecoxib (Celebrex; rithm, anesthesiologists generally follow either Pfizer, New York, N.Y.)] should be considered. a “risk-adapted approach” or a “fixed combina- Recent studies with agents such as ketorolac dem- tion” protocol for nausea prophylaxis. The risk- onstrate significant reductions in postoperative adapted approach evaluates a patient’s individual narcotic use, which translates into decreased rates risk factors and is more selective when choosing of PONV. Although there has been concern that multimodal antiemetic therapy, allowing for more nonsteroidal use would increase the risk of post- appropriate use of resources. Many electronic operative bleeding, Stephens et al. revealed no medical record systems offer patient-specific sup- increased risk of hematoma formation in patients port for risk stratification (known as “clinical who received ketorolac.29 Acetaminophen has decision support systems”), and provide thera- been shown to reduce postoperative narcotic use peutic recommendations using the risk-adapted and thus theoretically decreases the risk of PONV. approach. A “fixed combination” approach limits Patient-specific risk factors, such as liver disease, risk stratification and simply allows the anesthe- must be considered when choosing an agent and sia provider to offer at least two preventative mea- its specific dose. sures to any patient at risk for PONV.19 Intraoperative placement of long-acting local Most anesthesiologists treat patients with two anesthesia has been shown to decrease use of or more general risk factors, or a specific his- narcotics postoperatively. Injectable liposomal tory of postoperative nausea, with two different bupivacaine can be diluted with up to 280 cc of antiemetic therapies. Although treatments vary normal saline, allowing the surgeon significant among institutions, prevention usually requires volume for injection and nerve blockade in even blockade of the cholinergic, histaminergic, dopa- the largest of operations. Although liposomal minergic, or serotonergic system. Higher risk bupivacaine is currently only U.S. Food and Drug patients are treated with two different medica- Administration–approved for hemorrhoidectomy tions, usually affecting two different systems. A and bunionectomy, several studies have supported scopolamine transdermal patch (Transderm Scop; its off-label use in breast reconstruction and body Sandoz/Novartis, Princeton, N.J.) may be applied contouring procedures with pain control for 24 4 or more hours before surgery and offers anti- hours and beyond.21–24 Local anesthetic-contain- cholinergic effects for up to 72 hours.6 Aprepitant ing “pain pumps” using small catheters to slowly (Emend; Merck, Kenilworth, N.J.), an oral neuro- diffuse the local anesthetic into a wound site offer kinin blocker taken approximately 2 hours before another method of controlling pain for up to 2 a procedure, has a prolonged effect and has been days without narcotics. A less expensive alterna- shown to have excellent antiemetic qualities. tive that offers a benefit in the early postoperative However, its price point (approximately $100 per period is injectable bupivacaine hydrochloride. tablet) has limited its wider use.27,28 Ondansetron Although the onset of action is rapid, its half-life (Zofran; Novartis, Princeton, N.J.) is a serotonin is only 2.7 hours in adults; thus, longer term pain antagonist that offers postoperative coverage control is still an issue.25 when given just before extubation and is often used as a first-line agent because of widely held Refractory PONV/Postdischarge Nausea and acceptance of its minimal complication profile. Vomiting and Treatment after Prophylaxis In addition, low-dose corticosteroids such as dexa- When nausea or vomiting persists, further methasone (4 to 8 mg) are often given after induc- evaluation of the patient for causative agents is tion but with caution in patients with impaired required. Morphine is notorious for exacerbating glucose control.19 Although most antiemetics can nausea. Furthermore, mechanical obstruction of be readministered after 6 hours, repeated doses the gastrointestinal tract, or the drainage of blood of dexamethasone and scopolamine are generally into the gastrointestinal tract after head and neck not recommended. A detailed list of prophylaxis surgery, can result in discomfort and nausea. and treatment options is given in Table 2. If antiemetic prophylaxis was not previously Intraoperative opioids are associated with an used, a serotonin antagonist, such as ondanse- increased risk of PONV.6,16 Preoperative discus- tron, can be the first treatment choice. If a sero- sion with the anesthesia team regarding the like- tonin antagonist is not effective, it should not be lihood and degree of opioid use is essential. As repeated, as studies have shown no additional ben- previously mentioned, nonnarcotic pain control efit.9 Instead, drugs from other antiemetic classes

should be considered. Although droperidol (Inap- Shortcomings limiting the wider use of non- sine; Taylor Pharmaceuticals, Decatur, Ill.) and pharmacologic interventions include the vari- promethazine (Phenergan; Aventis, Surrey, United ability in how different modalities are provided, Kingdom) are often chosen as second-line agents, and the lack of randomized controlled trials, side effects of QT prolongation and sedation must compared with those involving drug administra- be closely monitored. If nausea and vomiting per- tion.11,34 However, the evidence for use of some sist, repeated doses of serotonin antagonists every nonpharmacologic modalities cannot be ignored. 6 hours should be considered, along with alter- One randomized controlled trial showed a statisti- nating doses of a second-line agent such as dro- cally significant reduction in PONV when two acu- peridol.6 Repeated dosages of corticosteroids have puncture points were used instead of one point shown no benefit and offer no rescue relief.6,8,9 (70 percent versus 86 percent).21 Another double- The incidence of nausea and vomiting fol- blind, randomized, controlled trial demonstrated lowing discharge (postdischarge nausea and that acupoint stimulation offered added protec- vomiting) is reported to be between 33 and 60 tion against PONV in an outpatient aesthetic percent. Reported incidences of postdischarge surgery population compared with standard treat- nausea range from 0 to 60 percent, whereas post- ment.33 A meta-analysis of 19 randomized con- discharge vomiting incidences range from 0 to 20 trolled trials concluded that nonpharmacologic percent. Symptoms tend to decrease with each techniques were equivalent to commonly used successive postoperative day but can last as long as antiemetic drugs in preventing PONV. Although 1 week after surgery.8,12,13,30,31 The true incidence is these modalities were more effective than placebo probably closer to the higher number because of in preventing PONV within 6 hours of surgery underreporting.13,32 in adults, there was no observed benefit in chil- In addition, postdischarge nausea and vomit- dren.34 Therefore, surgeons should be aware of ing leads to significant impairment in quality of life, these nontraditional options and consider incor- return to normal function, and return to work fol- porating them into practice. lowing ambulatory surgery. Postdischarge nausea is Some patients may ask about the use of mari- probably more significant than postdischarge vom- juana for PONV. Cannabinoids such as tetrahydro- iting in this effect. The economic impact can be sig- cannabinol, the active ingredient in marijuana, nificant but is not yet fully understood, as there are and dronabinol have been shown to be moder- few data on the increased cost of care for this con- ately effective in the treatment of chemotherapy- dition.8,11,12,30,32 Specific literature to support treat- induced nausea and vomiting.35 Evidence-based ment recommendations for postdischarge nausea studies have not demonstrated these drugs to be and vomiting (as compared to PONV or nausea effective in the postoperative patient. Although caused by other conditions) does not exist. many states have legalized medical marijuana, and a few states have legalized recreational mari- Nonpharmacologic PONV Reduction/Treatment juana, federal law still prohibits its use. A federal Evidence suggests that nonpharmacologic court ruled that it is not illegal for a physician to interventions to treat and prevent PONV may be discuss the use of marijuana with a patient. How- effective, economical, and feasible to implement ever, plastic surgeons should verse themselves in in practice. These include acupuncture, acupres- their particular state’s regulations before making sure, acupoint stimulation, and transcutaneous any recommendations to a patient, as this may be electrical nerve stimulation. These modalities a rapidly changing landscape. may facilitate reduction in proemetic narcotic use for pain control and have a direct impact on PONV symptoms. Acupuncture, applying needles CONCLUSIONS AND FUTURE on specific skin points, potentially stimulates the DIRECTIONS release of endorphins to relieve pain. Acupres- It is clear that postoperative/postdischarge sure applies therapeutic pressure to certain body nausea and vomiting presents an extensive prob- points. Acupoint stimulation involves a combina- lem. Although most of the literature is general- tion of acupuncture, cupping therapy (applica- ized, the field of plastic surgery demonstrates tion of external negative pressure to a body point an increasing focus on scientific investigation in to promote blood flow), and electrical stimulation this area.20,36,37 It is to be emphasized that plastic to ease pain. Transcutaneous electrical nerve stim- surgery–specific studies demonstrate very high ulation uses low-voltage electrical current for pain prevalence of this disease.36,37 Most plastic sur- relief.21,33,34 geons would agree that a complication estimated

Table 3. Tabular Summary of Summary b. Surgery: Use local anesthetic modalities Recommendations when possible (both short- and long-term), minimize surgical duration,10,18,19 protect Prevention Education gastrointestinal tract from blood (head and Patients neck cases) with throat packs or suction.10 Care team c. Postoperative: Use local anesthetics, Surgeon Risk factor minimization nonsteroidal antiinflammatory drugs, Preoperative acetaminophen (oral or intravenous), Intraoperative cyclooxygenase-2 inhibitors, or tapen- Postoperative Treatment tadol as alternatives or adjuncts to nar- PONV cotic medications for pain control.18,19 Pharmaceutical choice d. Optimize hydration and minimize ortho- Treatment timing 10 PDNV static hypotension. Pharmaceutical choice 3. Use a risk-prediction tool to guide prophy- Treatment timing 18,19 Assess for other causes lactic interventions. PONV, postoperative nausea and vomiting; PDNV, postdischarge 4. Use postoperative/postdischarge nausea nausea and vomiting. and vomiting prophylaxis based on relative cost-to-benefit analyses. in some studies to effect one-third of patients and a. Consider more liberal prophylaxis to have such severe consequences as decreased when there is increased risk (wired jaws, satisfaction, delay in discharge, and hematoma increased intracranial pressure, gastric/ must be scrutinized for opportunities for further esophageal surgery) or a “strong prefer- 36–38 improvement. ence to avoid PONV” exists.18 There is great occasion for collaboration between b. Consider one to two interventions for specialties. Currently, it appears that plastic surgery moderate-risk adults and two or more patients benefit from the same recommendations as interventions for moderate-risk chil- 36,37 other surgical populations. This is advantageous, dren. Use two or more interventions for as the complexity of treatment options makes repli- all high-risk patients.18,19 cation of similar interventions in a variety of differ- c. When choosing multimodal therapy, ent surgical populations cumbersome. Apfel et al. choose agents with different mecha- highlight this principle in their investigation into nisms of action.18 Consider time to onset the relative benefits of six potential prophylactic of action when using multimodal ther- regimens as applied to populations of varying risk apy and choose agents with appropriate 38 profiles. Further areas of multidisciplinary engage- risk profiles.19 ment that are bearing fruitful observations include 5. Treat occurrences of PONV aggressively.18 enhanced recovery after surgery protocols, many of which focus some interventions on postoperative/ a. If prophylaxis was used, choose treat- postdischarge nausea and vomiting.39,40 It is expected ment from another pharmacologic class. that further evidence in this still somewhat nascent b. Without previous prophylaxis, first con- area will be shortly forthcoming. sider a serotonin antagonist. c. Do not repeat drugs used until 6 hours has elapsed after completion of surgery. SUMMARY RECOMMENDATIONS d. Do not repeat use of dexamethasone or 1. Be aware of and actively educate patients on transdermal scopolamine. postoperative/postdischarge nausea and e. If refractory symptoms persist: evaluate vomiting and potential consequences pre- for other factors such as narcotic use, operatively (Table 3). draining blood into gastrointestinal tract, 2. Decrease risk factors when possible18: or gastrointestinal obstruction/ileus. a. Anesthesia: Minimize the use of volatile 6. Postoperative/postdischarge nausea and anesthetic agents in higher risk patients vomiting can occur despite optimal pro- and substitute propofol for induction and phylaxis and treatment. Communication maintenance, avoid nitrous oxide and between patient, anesthesiology team, sur- neostigmine, minimize intraoperative opi- gical team, and perioperative nursing staff oids, and provide adequate hydration.18 is essential.20

7. Consider individual in-depth study of C. Bob Basu, M.D., M.P.H. any of the published reviews or guide- Basu Center for Aesthetics & Plastic Surgery lines that detail potential optimal specific 6400 Fannin Street drugs and drug combinations in particu- Suite # 2100 Houston, Texas 77030 lar clinical situations beyond the scope of [email protected] this article. Periodic review will be necessary, as the body of evidence will likely increase and allow refinement of current REFERENCES techniques. 1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States. Natl Health Stat Reports 2009;28:1–25. 2. Horn CC, Wallisch WJ, Homanics GE, Williams JP. MORE INFORMATION Pathophysiological and neurochemical mechanisms Most anesthesiologists and anesthetists are of postoperative nausea and vomiting. Eur J Pharmacol. well acquainted with risk assessment and treat- 2014;722:55–66. 3. Lee YZ, Lee RQ, Thinn KK, Poon KH, Liu EH. 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Current concepts in the management of postoperative nausea and vomiting. gists website: Anesthesiol Res Pract. 2011;2011:748031. https://asahq.org 7. Chung F, Mezei G. Factors contributing to a prolonged stay https://asahq.org/search.aspx?q=PONV after ambulatory surgery. Anesth Analg. 1999;89:1352–1359. http://www.asahq.org/resources/publica- 8. Pan PH, Lee SC, Harris LC. Antiemetic prophylaxis for postdis- tions/newsletter-articles/2002/april2002/ charge nausea and vomiting and impact on functional quality of living during recovery in patients with high emetic risks: A therapy-of-ponv-an-overview prospective, randomized, double-blind comparison of two pro- Other sources include the following: phylactic antiemetic regimens. Anesth Analg. 2008;107:429–438. http://www.ncbi.nlm.nih.gov/ 9. Wesmiller SW, Bender CM, Sereika SM, et al. 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Anesth Analg. 1995;80:903–909. sory to Etiology, Impact, and Treatment.” It is directed 13. Apfel CC, Philip BK, Cakmakkaya OS, et al. Who is at risk for postdischarge nausea and vomiting after ambulatory sur- toward plastic surgeons that discharge their patients on gery? Anesthesiology 2012;117:475–486. the same day of surgery, regardless of the facility setting; 14. Eberhart LH, Geldner G, Kranke P, et al. The development it is also applicable to inpatient care. and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients. Anesth Analg. DISCLAIMER 2004;99:1630–1637, table of contents. 15. van den Bosch JE, Kalkman CJ, Vergouwe Y, et al. Assessing This advisory is based on the most relevant infor- the applicability of scoring systems for predicting postopera- mation available and reflects the collective opinion tive nausea and vomiting. Anaesthesia 2005;60:323–331. of the American Society of Plastic Surgeons Patient 16. Kim SH, Shin YS, Oh YJ, Lee JR, Chung SC, Choi YS. Risk Safety Subcommittee. It is not an exhaustive list of assessment of postoperative nausea and vomiting in the intra- postoperative nausea and vomiting prevention and venous patient-controlled analgesia environment: Predictive values of the Apfel’s simplified risk score for identification of treatment options. This document is meant as an high-risk patients. Yonsei Med J. 2013;54:1273–1281. overview, with additional resources included for more 17. Apfel C, Kranke P, Eberhart L. Comparison of surgical site information. and patient’s history with a simplified risk score for the

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