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Can ponv be predicted

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Can PONV be predicted? Risk factor analysis
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Page 1: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Can PONV be predicted?

Risk factor analysis

Page 2: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

• Use of prophylactic antiemetics should be based on valid assessment of the patients risk for POV or PONV.

• In other words....antiemetic prophylaxis shouild be used only when the patient individual risk is sufficiently high.

• Estimate:baseline risk * baseline risk reduction resulting from prophylaxisUse of prophylactic antiemetics should be based on

• This approach produces a clinically meaningful decrease in the risk of PONV

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk Factors

• Female• Nonsmoking history • Hx of motion sickness or PONV• Use of postoperative opioids

Simplified Scoring System

Incidence of PONVRisk Factors Incidence

0 10%

1 21%

2 39%

3 61%

4 79% Apfel CC et al. Anesthesiology 1999;91:693-700.

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Simplified scoring system from Apfel for adults

• For every risk factor the sum is additive:

• Point 0 risk 10%

• Point 1 risk 20%

• Point 2 risk 40%

• Point 3 risk 60%

• Point 4 risk 80%

Page 5: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Simplified risk score from Apfel et al. to predict thepatients risk for PONVin adults . When 0, 1, 2, 3, or 4 of the depicted independent predictors are present, the corresponding riskfor PONV is approximately 10%, 20%,

40%, 60%, or 80%.

Figure 1

Page 6: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Simplified scoring system from Eberhardt 39 di Samba for children

• Surgery> 30 min

• Age> 3

• Strabismus surgery

• Hx of POV or POnv in relatives

• Sum 0......4

• Risk 10%,10%,30%,55%,70%

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Simplified risk score from Eberhart et al. (39) to predict therisk for POV in children. When 0, 1, 2, 3, or 4 of the depictedindependent predictors are present, the corresponding risk

for PONV is approximately 10%, 10%, 30%, 55%, or 70%.

Page 8: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Particular medical risk

• more liberal prophylaxis is appropriate for patients in whom vomiting poses a particular medical risk:

• wired jaws

• increased intracranial pressure

• gastric or esophageal surgery

• when the anesthesia care provider determines the need

• or the patient has a strong preference to avoid PONV

Page 9: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Sinclair et al.Can PONV be predicted?Anesthesiology 1999;91:109-18

• 17,638 consecutive ambulatory surgical patients;>90% ASA I /II• 5,812 men and 11,826 women• mean (± SD) age of 46.7 ± 21.2 yr.• prospectively studied during a 3-yr period • ASU of The Toronto Hospital, Western Division• telephone interview 24 h after operation was obtained. • Preoperative patient characteristics and intraoperative variables were

documented on specifically designed, standardized adverse-outcome check-off forms.

• i.v.2—4 mg morphine for pain relief and 25—50 mg dimenhydrinate for nausea or vomiting.

• Overall PONV incidence 4.6%:9.1 % at 24 hrs interview.

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Independent predictors of PONVSinclair et al.Can PONV be predicted?Anesthesiology 1999;91:109-18

• age A 10-yr increase in age was associated with a 13% decrease in the likelihood of PONV.

• sex Men had one third the risk for PONV compared with women.

• smoking status Smokers had two thirds the risk for PONV compared with nonsmokers

• history of previous PONV, had a threefold increase in the likelihood PONV compared with patients with no previous PONV.

• type of anesthesia: General anesthesia increased the likelihood of PONV 11 times compared with other types of anesthesia.

• duration of anesthesia, direct association between the duration of anesthesia and the risk for PONV. A 30-min increase in duration predicted a 59% increase in the incidence of PONV

• type of surgery :– plastic surgery had a sevenfold increase in the risk for PONV.– orthopedic shoulder surgery, ophthalmologic, or ENT procedures had a four- to sixfold increase.

– orthopedic (nonshoulder) and gynecologic (non-D&C) procedures had a threefold increase in the risk for PONV. Compared with the reference group, which includes general surgery, gynecologic dilation and curettage (D&C), urologic surgery, neurosurgery, and chronic pain blockENT

– dental surgery 14.3%, orthopedic 7.6%,plastic surgery 7.4%.Urologic, gynecologic, neurologic, or general surgery had an incidence of PONV corresponding to the overall average 4%

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Logistic regression da:Sinclair et al.Can PONV be

predicted?Anesthesiology 1999;91:109-18

• P=1/1+e esponente

• con il segno neg. all’esponente la probabilità aumenta perché e elevato ad esp negativo diminuisce sempre + con il risultato che 1+e tende a 1 e dunque P=1/1,ossia 100%

• Con il segno positivo all’esponente e aumenta sempre + e allora 1+e aumenta e dunque il denominatorer dell’equazione aumenta e dunque 1/un numero in aumento fa scendere la probabilità perché viene 1/5,cioè 20%,1/10=10%,ecc…..

• Esponente=-5,97+(-0,14 *age)+(-1,03*sex)+(-0,42*smoke)+(1,14*PONV history)+(0,46*duration)+(2,36*GA)+(1,48*ENT)+(1,77*ophtalm)+(1,90*plastic)+(1,20 Gynecol non DC)+(1,04 ort knee)+(1,78*ortshoulder)+(0.94

ort other)• where Age = age in years/10; Sex = 1 if male and 0 if female; Smoke = 1 if smoker and 0 if nonsmoker; PONV

History = 1 if previous PONV and 0 if no previous PONV; Duration = duration of surgery in 30-min increments; GA = 1 if general anesthesia and 0 if other type of anesthesia; ENT = 1 if ENT and 0 if other type of surgery; Ophthalm = 1 if ophthalmology and 0 if other type of surgery; Plastic = 1 if plastic surgery and 0 if other type of surgery; GynNonDC = 1 if gynecologic non D&C procedure and 0 if other type of surgery; OrtKnee = 1 if orthopedic procedure involving knee and 0 if other type of surgery; OrtShoulder = 1 if orthopedic procedure involving the shoulder and 0 if other type of surgery; OrtOther = 1 if orthopedic procedure involving neither knee nor shoulder and 0 if other type of surgery.

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Importance of the work by Sinclair et al…

• Fitting the model to the data, we can obtain the maximum likelihood estimate of the parameters for each variable. Based on the maximum likelihood estimates from the final models, it is possible to calculate an expected risk of occurrence of the specific adverse event for any patient.

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

• Appendix 1 • Logistic regression is used to model the relation between explanatory variables and binary outcome variables. The logistic regression

modeling assumes that the probability of an event (i.e., the occurrence of the outcome) is associated with the values of the explanatory variables in the following way:

• where •

• where p = probability of the occurrence of the outcome, xi = value of the ith independent variable, and bi events for any patient = parameter estimates for the ith variable.

• Fitting the model to the data, we can obtain the maximum likelihood estimate of the parameters for each variable. Based on the maximum likelihood estimates from the final models, it is possible to calculate an expected risk of occurrence of the specific adverse event for any patient.

• Examples• The risk for patient 1, a 30-yr-old woman with a history of smoking and previous PONV undergoing a 1-h shoulder (orthopedic)

operation with general anesthesia is 35.2%. •

• The risk for patient 2, a 40-yr-old nonsmoking man with no previous PONV undergoing a 1-h knee arthroscopy (orthopedic) without general anesthesia is 0.4%.

• The risk for patient 3, a 70-yr-old smoking man with no previous PONV undergoing a 1-h cataract surgery (ophthalmologic) without general anesthesia is 0.3%.

• The risk for patient 4, a 32-yr-old nonsmoking woman with previous PONV undergoing a 30-min laparoscopy (gynecologic) with general anesthesia is 22.1%

• The risk for patient 5, a 22-yr-old woman with a history of smoking and previous PONV undergoing a 90-min bilateral breast augmentation (plastic surgery) with general anesthesia is 52%.

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Strategies to Reduce Baseline Risk

• Avoidance of general anesthesia by the use of regional anesthesia (11,16) (randomized, controlled trial, RCT)

• Use of propofol for induction and maintenance of Anesthesia(4,14,41,42) (RCT/systematic review, SR)

• Avoidance of nitrous oxide (3,4,43,44) (RCT/SR)

• Avoidance of volatile anesthetics (15,28) (RCT)

• Minimization of intraoperative (SR) and postoperative

• opioids (3,13,15,17,18,20,28,43) (RCT/SR)

• Minimization of neostigmine (19,45) (SR)

• Adequate hydration (46) (RCT)

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk Factors

• Non-anesthetic factors

• Anesthetic related factors

• Postoperative factors

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk factors da Samba 2007:1

• Patient specific

– Female gender

–Non smoking status

–Hx of ponv/motion sickness

Page 17: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk factors da Samba 2007:2

• Anesthetic risk factors

–Use on intraop volatile anesth

–Use on intraop and postop opioids

–Use of intraop N2O

Page 18: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk factors da Samba 2007:3

• Surgical risk factors– Duration of surgery

– Each 30 min increase in duration of surgery oncreases the risk by 60%,so thyat a baseline risk of 10% increases to 16% after 30 min

– Type of surgery Laparoscopy;,laparotomy;breast,strabismus,plastic,maxi

llofacial,gynecological,abdominal,neurologic ,opthalmologic,urologic

Page 19: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk Factors

• Age

• Gender

• Body habitus

• Hx motion sickness

• Hx PONV

• Anxiety

• Concomitant disease

• Operative procedure

• Duration of surgery

Non-anesthetic Factors

Page 20: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk Factors

• Preanesthetic medication

• Gastric distension

• Gastric suctioning

• Anesthetic technique

• Anesthetic agents

Anesthetic Related Factors

Page 21: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk Factors

• Pain

• Dizziness

• Ambulation

• Oral intake

• Opioids

Postoperative Factors

Page 22: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Postoperative Nausea and Vomiting:Anesthetic Related Factors

• Nitrous oxide

• Volatile anesthetics

• NMB reversal

• Propofol

Page 23: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk FactorsNitrous Oxide and PONV

• Decreases POV significantly only if the baseline risk is high

• Does not affect nausea or complete control of emesis

• Increases the incidence of intraoperative awareness

Omitting nitrous oxide from general anesthesia:

Tramer et al. BJA 1996;76:186-193

Page 24: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

IS PONV incidence different between LMA and ETT?

• Joshi GP, Inagaki Y, White PF, Taylor-Kennedy L, Wat LI, Gevirtz C, McCraney JM, McCulloch DA: Use of the laryngeal mask airway as an alternative to the tracheal tube during ambulatory anesthesia. Anesth Analg 85:573–7, 199

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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk FactorsVolatile anesthetics

Risk Factors OR* CI

Volatile

anesthetics

isoflurane 3.41 2.18; 5.37

sevoflurane 2.78 1.79; 4.31

enflurane 3.11 1.98; 4.88

Apfel et al. BJA 2002;88:659-668

* Compared to propofol

Page 26: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk FactorsReversal of Neuromuscular Block

• Omitting neostigmine may have a clinically relevant antiemetic effect when high doses are used

• Omitting NMB antagonism introduces a non-negligent risk of residual paralysis even when short acting NMB agents are used

Tramer MR, Fuchs-Buder T. BJA 1999;82:379-386

Page 27: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk Factors Propofol and PONV

Early Late

NauseaVomitingAnyNauseaVomitingAny

Induction 9.3* 13.7* 20.9 50.114.9NA

Maintenance 8* 9.2* 6.2* 5.8* 10.1* 10

Early Late

NauseaVomitingAnyNauseaVomitingAny

Induction 5.0* 7.0* 14 28 10 NA

Maintenance 4.7* 4.9* 4.9* 6.1* 8.3* 7.1

All Control Event Rates

20% - 60% Control Event Rate

Tramer et al. BJA 1997;78:247-255

Analysis by NNT

Page 28: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk Factors Antiemetic Effects of Propofol

Investigations Randomized Double-Blind Placebo-Controlled Effective

Chemotherapy Induced Emesis

Scher 1992 no no no yes

Borgeat 1993 no no no yes

Borgeat 1994 no no no yes

PONV

Campbell 1991 yes yes yes no

Borgeat 1992 yes yes yes yes

Ewalenko 1996 yes yes yes yes

Montgomery 1996 yes yes yes no

Scuderi 1996 yes yes yes no

Gan 1997 no no no yes

Gan 1999 yes yes yes yes

Page 29: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk Factors

Palazzo M, Evans R. Logistic regression analysis of fixed patient

factors for postoperative sickness: a model for risk assessment. Br J

Anaesth 1993;70:135-40.

Koivuranta M, Läärä E, Snåre L, Alahuhta S. A survey of postoperative

nausea and vomiting. Anaesthesia 1997;52:443-49.

Apfel CC, Greim CA, Haubitz I, et al. A risk score to predict the

probability of postoperative vomiting in adults. Acta Anaesthesiol Scand

1998;42:495-501.

Logistic Regression

Page 30: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Risk Factors

• Younger age

• Nonsmoking history

• Female

• Hx of motion sickness

• Hx of PONV

• Increased duration of operation

Logistic Regression

Page 31: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Problems............

• to separate independent factors vs dependent factors................

• No risk model can actually predict the likelihood of an individual having PONV;risk models only allow clinicians to etimate the risk of PONV among patients groups

Page 32: Can ponv be predicted

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

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