DOI: 10.31038/ASMHS.2022634

Introduction

Recovery following anesthesia is usually complicated by nausea, vomiting, and retching. PONV (postoperative nausea and vomiting) is a significant concern; people frequently regard PONV as terrible than postoperative pain [1]. PONV normally clears up or is treated without repercussions, although it may need an unexpected admittance to the hospital and cause a delay in discharge [2,3].

In this article, we’ll go over a few points concerning PONV risk factors that you should be aware of.

Pathophysiology

Nausea and vomiting are mediated by five neurotransmitter receptors: neurokinin 1 (NK1) – substance P, dopamine D2, muscarinic M1, 5-hydroxytryptamine (HT)-3 serotonin, and histamine H1. PONV might be prevented or treated by targeting any of these receptors [4].

• Central mechanisms – Higher centers of cortex connecting with the central pattern generator (previously known as the center of vomiting) in the medulla can cause nausea and emesis. Anxiety, pain, conditioned nausea which is triggered by environmental cues, fear, and vestibular system stimulation are all major stimuli that can elicit nausea and vomiting during the perioperative period. During tympanoplasty, for example, surgical activation of the vestibular system via the H1 histamine and M1 cholinergic receptors may cause severe PONV [5].
• Mechanisms in the periphery – Direct stimulation of the stomach from gastric injuries, bleeding, or toxins causes enterochromaffin cells to produce substance P and serotonin, activating the 5-HT3 receptors in the vagal and splanchnic nerves [6].
• Toxins and Drugs – The chemical and neurological processes by which medications and toxins elicit nausea and vomiting, including anesthetics and opioids, are complicated and poorly understood [7]. Both opioids and inhalation anesthetics can cause nausea and vomiting by activating the area postrema directly beneath of the fourth ventricle in the medulla. The postrema then transmits dopamine and serotonin to the central pattern generator, which causes the vomiting reflex to be triggered [8,9].

Risk Factors

PONV develops in roughly 30% of infants and adults following anesthesia without prophylaxis [10]. The risk of PONV varies greatly from patient to patient; in high-risk individuals, the rate of PONV might be 80% [11]. The risk of PONV varies depending on the patient, the anesthesia used, and even the type of operation.

Patient Risk Factors

• Nausea and vomiting before surgery – PONV might be the outcome of a pre-surgery ailment that caused nausea and vomiting.
• Female gender – Female gender is the most accurate patient-specific predictor of PONV [12,13].
• Prior to puberty, female children do not have an increased risk of PONV [14,15].
• Patients who have already had PONV or motion sickness – Previous PONV and/or motion sickness increase the risk of PONV in adults [16].
• A parent or sibling’s history of PONV or postoperative vomiting (POV), as well as a parent or sibling’s history of PONV or POV, increases the risk of POV/PONV in children [17].
• Being a nonsmoker – Being a nonsmoker is a risk factor for PONV in and of itself [12,13,16].
• Age – The majority of research have found a minor, gradual decline in PONV in people as they get older [10,12]. The age of 50 was found to be a risk factor for PONV in a prospective trial of over 2200 patients who received general anesthesia (PDNV) [18].
• Young age seems to be protective in children. POV is uncommon in youngsters under the age of three, and it becomes more common as they become older, with puberty it reduces again [14].
• Chemotherapy-induced nausea and vomiting – A background of chemotherapy-induced nausea and vomiting may aggravate PONV (CINV) [19].

Anesthetic Factors

• Anesthetic technique – When compared to simply regional anesthesia, general anesthesia is linked to a greater rate of PONV [16].
• Total intravenous anesthesia versus Volatile anesthetics – The use of volatile anesthetics is a major factor in the development of PONV [16,20].
• Intravenous (IV) anesthetics – At dosages routinely used for induction of anesthesia, etomidate does not raise PONV on its own [21]. Low-dose ketamine in the perioperative period has been shown to minimize PONV, as well as postoperative pain and opioid needs [22,23].
• Nitrous oxide (N₂O) – When compared to anesthesia without N₂O, N₂O may slightly increase the incidence of PONV, particularly in children and high-risk individuals [24].
• Duration of anesthesia – Anesthesia for longer periods of time using volatile anesthetics may raise the incidence of PONV [12,13,25].
• Opioid administration and decrease – Several studies have found that perioperative opioid administration increases the risk of PONV in a dose-dependent way [11,16,26].
• Neostigmine versus Sugammadex for reversal agent – As shown in a meta-analysis of 10 randomized studies including 933 individuals, combining neostigmine with either atropine or glycopyrrolate did not significantly enhance the incidence of overall nausea or vomiting [27].
• It’s uncertain how common PONV occurs once sugammadex is used to reverse neuromuscular blocking medications.

Type of Surgery

When compared to other general surgical operations, the best data shows that cholecystectomy, laparoscopic, and gynecologic surgeries are linked with a moderately elevated risk of PONV [12].

In children, strabismus operation is a significant, and arguably the most critical, predictor of POV [14,17]. POV also happens in up to 70% of children who undergo adenotonsillectomy without prophylaxis [28], 60% of kids who have otoplasty [29], and 40% of children who have inguinal scrotal or penile surgeries [30].

In conclusion, PONV is a condition with distinct characteristics that can be avoided by recognizing preventive causes. In our review, we have covered several noteworthy elements.

References

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