P1: Trim: 8.375in × 10.875in Top: 0.373in Gutter: 0.
664in
LWBK915-06 LWW-KodaKimble-educational
POSTOPERATIVE NAUSEA AND VOMITING
1 The risk of postoperative nausea and vomiting depends on several patient, surgical
and anesthetic factors. The antiemetic regimen should be proportional to the risk
factors.
2 The most active agents in preventing postoperative nausea and vomiting are 5-HT3
antagonists. For patients at moderate to high risk, a 5-HT3 antagonist should be
combined with dexamethasone or droperidol. Antiemetics used for rescue therapy
should be of a different class than the prophylaxis agents used.
DEFINITION
Nausea and vomiting are unpleasant symptoms caused by self-
limiting disorders or serious conditions such as cancer. These
symptoms can range from mild, short-lived nausea to contin-
uing severe emesis and retching. The emetic response can be
described in three phases: nausea, vomiting, and retching. Nau-
sea is the subjective feeling of the need to vomit. It includes an
unpleasant sensation in the mouth and stomach and can be asso-
ciated with salivation, sweating, dizziness, and tachycardia. Vom-
iting is the forceful expulsion of the stomach contents through
the mouth, but is preceded by the relaxation of the esophageal
sphincter, contraction of the abdominal muscles, and temporary
suspension of breathing. Retching is the rhythmic contraction of
the abdominal muscles without actual emesis. It can accompany
nausea, or occur before or after emesis.
EPIDEMIOLOGY AND CLINICAL
PRESENTATION
Nausea and vomiting are caused by many disorders. Central ner-
vous system (CNS) causes include increased intracranial pres-
sure, migraine headaches, brain metastases, vestibular dysfunc-
tion, alcohol intoxication, and anxiety. Infectious disease causes
include viral gastroenteritis, food poisoning, peritonitis, menin-
gitis, and urinary tract infections. Metabolic causes include
hypercalcemia, uremia, hyperglycemia, and hyponatremia. Gas-
trointestinal disorders, such as gastroparesis, bowel obstruction,
distension, and mechanical irritation, can cause nausea and vom-
iting. Among the many medications that can cause nausea and
vomiting are cancer chemotherapy, antibiotics, antifungals, and
opiate analgesics.
In addition to the suffering involved, uncontrolled vomiting
can lead to dehydration, electrolyte imbalances, malnutrition,
aspiration pneumonia, and esophageal tears. Nausea and vom-
iting often reduces food intake and can impair a person’s ability
to care for himself or herself. Significant reductions in quality-
of-life scores have been demonstrated in cancer patients with
chemotherapy-induced nausea and vomiting compared with
patients who did not have those symptoms.1
PATHOPHYSIOLOGY
The CNS, the peripheral nervous system, and the gastrointestinal
(GI) tract are all involved in initiating and coordinating the emetic
response. In the CNS, the vomiting center (VC) receives incom-
November 17, 2011 16:23
99
CHAPTER CASES
Chapter 6
Case 6-4 (Question 1),
Table 6-6
Case 6-4 (Question 1),
Nausea and Vomiting
Table 6-6
ing signals from other parts of the brain and the GI tract and then
coordinates the emetic response by sending signals to the effector
organs. The VC is located in the medulla oblongata of the brain,
near the nucleus tractus solitarius (NTS). The VC is stimulated
by neurotransmitters released from the chemoreceptor trigger
zone (CTZ), the GI tract, the cerebral cortex, the limbic system,
and the vestibular system (Fig. 6-1). The major neurotransmitter
receptors associated with the emetic response include sero-
tonin (the 5-hydroxytryptamine type 3, [5-HT3 ]) receptors, neu-
rokinin 1 (NK1) receptors, and dopamine receptors. Other recep-
tors involved include corticosteroid, acetylcholine, histamine,
cannabinoid, gabaminergic, and opiate receptors. Many of these
receptors are targets for antiemetic therapy.
In the CNS, the CTZ is located in the area postrema on the
floor of the fourth ventricle in the brainstem; it lies outside the
blood–brain barrier. When the CTZ senses toxins and noxious
substances in the blood or cerebrospinal fluid, it triggers the
emetic response by releasing neurotransmitters that travel to
the VC and the NTS. The major neurotransmitter receptors
include serotonin, dopamine, and neurokinin 1.
The GI system also plays a large part in the initiation of the
emetic response. The GI tract contains enterochromaffin cells in
the GI mucosa. When these cells are damaged by chemother-
apy, radiation, anesthetics, or mechanical irritation, serotonin is
released, which can stimulate the vagal afferents as well as directly
stimulate the VC and NTS. The vomiting center then initiates
the emetic response.
The cerebral cortex and limbic system can stimulate the
emetic center in response to emotional states such as anxiety,
pain, and conditioned responses (anticipatory nausea and vomit-
ing). The neurotransmitters involved in this pathway are less well
understood. Disorders of the vestibular system, such as vertigo
and motion sickness, stimulate the VC through acetylcholine and
histamine release.
DIAGNOSIS
The initial evaluation of the patient with nausea and vomiting
should include the onset of symptoms, the severity and dura-
tion of symptoms, hydration status, precipitating factors, current
medical conditions and medications, and food and infectious con-
tacts. The etiology of the nausea and vomiting should be deter-
mined, if possible, so that underlying conditions can be treated
specifically. Supportive treatment should be initiated, if needed,
including fluid and electrolyte replacement. If the nausea and
vomiting is mild and self-limited, antiemetic therapy may not be
required. For others, however, the appropriate antiemetic ther-
apy will depend on the patient and the etiology of the nausea
and vomiting.