NáUsea Y VóMito Postoperatorio En CirugíA Ambulatoria
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Transcript of NáUsea Y VóMito Postoperatorio En CirugíA Ambulatoria
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Náusea y vómito
postoperatorio en cirugía
ambulatoria
Diana Bolaños Arboleda
Residente Anestesiología
2009
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Introducción
• Efectos secundarios más comunes
• Incidencia 30% alto riesgo 70%
• Multifactorial
Pharmacology of Antiemetics. PE Scuderi. Int Anesth Clin, 2003
Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
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Introducción
Risk assessment of postoperative nausea and vomiting. C. Apfel. Int Anesth Clin, 2003
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Complicaciones
• Insatisfacción
• Neumonitis aspirativa
• Dehiscencia de suturas
• Ruptura esofágica
• Enfisema subcutáneo
• Neumotórax bilateral
• Hematomas
• Retarda el alta
A factorial trial of six interventions for prevention of postoperative nausea and vomiting. Nejm, Jun, 2004
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Introducción
• Un episodio de vómito retarda en PACU = 25 min
• 0.2% hospitalización no anticipada
• US$ 100 por terapia efectiva
Management of postoperative nausea and vomiting. T. Gan. ASA refresher 2008
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Definición
Postoperatorio
• Temprana
0 – 2 horas
• Tardía
2 – 24 horas
De alta
• “Discharge”
• PDNV
• 17% náusea - 8%
vómito
Pharmacology of Antiemetics. PE Scuderi. Int Anesth Clin, 2003
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Fisiopatología
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Centro vómito
(Bulbo raquídeo)
Zona quimiorreceptora
estimuladora
(Área postrema)
H1
M1
5 HT3D2
Corteza
Sistema LímbicoÁrea vestibular – visual
Vago
Haloperidol Ondansetrón
Metoclopramida
Escopolamina Dimenhidrinato
NK1Aprepitan
Dexametasona
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Factores de riesgo
• Identificar pacientes profilaxis
Beneficio
Prohibitivo
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Factores de riesgo
Técnica
anestésica
CirugíaPaciente
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Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
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Modelos de riesgo
• Apfel Adultos
• Eberhart Niños
• Clasificación del riesgo 70%
• PONV 30% - Recurrencia 50%
Risk assessment of postoperative nausea and vomiting. C. Apfel. Int Anesth Clin, 2003
Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
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Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
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Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
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Management of postoperative nausea and vomiting. T. Gan. ASA refresher 2008
Risk assessment of postoperative nausea and vomiting. C. Apfel. Int Anesth Clin, 2003
• 0 – 1 FR = 10 – 20%
Bajo
• 2 FR = 40%
Moderado
• 3 – 4 FR = 60 – 80%
Alto
Clasificación del Riesgo
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No factores de riesgo
• Obesidad
• Ansiedad
• Ciclo menstrual
• Experiencia del anestesiólogo
• Ventilación con máscara
facial
• SNG
Risk assessment of postoperative nausea and vomiting. C. Apfel. Int Anesth Clin, 2003
Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
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Reducción del riesgo de base
Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
O2 suplementario NO se recomienda en las guías
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Profilaxis
• No es costo/efectiva
• Bajo riesgo Efectos secundarios
• NNT (Número necesario a tratar) ≤ 4 =
efectividad clínica
Management of postoperative nausea and vomiting. T. Gan. ASA refresher 2008
Combination Antiemetics What Is the Evidence? A. Habib, T. Gan Int Anesth Clin,2003
Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
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Profilaxis
• Bajo riesgo NNT 10
• Se justifica desde riesgo moderado
• Alto riesgo Antieméticos + TIVA
Risk assessment of postoperative nausea and vomiting. C. Apfel. Int Anesth Clin, 2003
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Náusea
temprana
Náusea
tardía
Vómito
temprano
Vómito
tardío
Dexametasona 5 4.3 3.6 4.3
Ondansetrón 5.6 4.6 5.5 6.4
Propofol
inducción
9.3 5.0 13.7 14
Propofol
mantenimiento
8 5.8 9.2 10
Droperidol 4.8 5.8 6.9 3.4
Metoclopramida 16 12 9.1 10
Combination Antiemetics What Is the Evidence? A. Habib, T. Gan Int Anesth Clin,2003
NNT estudiados en revisiones sistemáticas
Dexametasona – Ondansetron = Mejor perfil
Metoclopramida = PEOR
Haloperidol 6 4
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Metoclopramida
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Terapia combinada
• 1 antiemético 26%
• Combinaciones = Efecto aditivo
• 2 ó + antieméticos (diferentes receptores)
superior que monoterapia
Combination Antiemetics What Is the Evidence? A. Habib, T. Gan Int Anesth Clin,2003
Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
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Terapia combinada
Dexametasona 4 mg + Ondansetrón 4 mg
Dexametasona 4 mg + Haloperidol 1 mg
Combination Antiemetics What Is the Evidence? A. Habib, T. Gan Int Anesth Clin,2003
Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
Management of postoperative nausea and vomiting. T. Gan. ASA refresher 2008
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Tiempo y dosis
Guidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
Dosis
adultos
Dosis
niños
Momento
aplicación
Dexametasona 4 mg 0.15 mg/kg
(hasta 4 mg)
Inducción
Ondansetrón 4 mg 50 – 100
mcg/kg
(hasta 4 mg)
Final
cirugía
Haloperidol 1 – 2 mg - Final
cirugía
The timing of haloperidol administration does not affect its prophylactic antiemetic efficacy. Can J Anesth 2008; 55:5, 270-75
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Aproximación multimodal
Técnica
anestésicaProfilaxis
98% de éxito en PACU
Management of postoperative nausea and vomiting. T. Gan. ASA refresher 2008
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IMPACT
International Multicenter Protocol to Assess the Single and
Combined Benefits of Antiemetic Interventions in a Controlled
Clinical Trial
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IMPACT
• 5199 pacientes, 2000 - 2002
• Aleatorizado, ciego
• Multicéntrico (28)
• Incidencia 34%
• ≥ 40% riesgo = 2 FR
• Md = 20 minutos de iniciar la anestesia
A factorial trial of six interventions for prevention of postoperative nausea and vomiting. Nejm, Jun, 2004
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• Resultados
Cada antiemético PONV 26%
- Propofol 19%
- No nitroso12%
- Remifentanil 5%
A factorial trial of six interventions for prevention of postoperative nausea and vomiting. Nejm, Jun, 2004
IMPACT
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• Conclusión
La más segura y menos $ = 1 opción
Dexametasona 4 mg
- Profilaxis
Bajo riesgo = No beneficio
Moderado = Al menos 1 intervención
Alto = Múltiples intervenciones
A factorial trial of six interventions for prevention of postoperative nausea and vomiting. Nejm, Jun, 2004
IMPACT
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No farmacológica
• P6
• Endorfinas y serotonina
• 19% Náusea, vómito. Rescate
• NNT 5 (temprana)
• Soportado por MBEGuidelines for the management of Postoperative Nausea and Vomiting. Anesth Analg 2007;105:1615–28
The effects of acupressure point P6 on PONV: A review of literature. J Perianesth nurs 2008;23, 4: 247- 61
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Rescate
• A TODOS Recurrencia 50%
• Al inicio de los síntomas
• Evaluar si hay causa
• Acción en otro receptor
• Ondansetron 1 mg – Propofol 20 mg
Risk assessment of postoperative nausea and vomiting. C. Apfel. Int Anesth Clin, 2003
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• Butirofenona
• Aprobado por la FDA desde 1967
• Efectos secundarios a dosis altas (35 mg/día)
• 1962 – 1988 primeras publicaciones = dosis bajas
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Adding haloperidol to morphine for patient-controlled analgesia (PCA) reduces nausea and vomiting after short stay surgery: a pragmatic trial
Luis E. Chaparro1
Julián A. Jaramillo2,
Catalina M. Martinez 1
Hector Manrique 3
Andres Castaño4
Alejandro R. Jadad 5
1. Department of Anaesthesia, University of Antioquia, Medellin, Colombia
2. Department of Anaesthesia, Pontificia Bolivariana University, Medellin, Colombia
3. Department of Anaesthesia, Clinica Las Americas, Medellin, Colombia
4. School of Medicine, University of Antioquia, Medellin, Colombia
5. Departments of Health Policy, Management and Evaluation; and Anaesthesia; and Dalla Lana School of Public Health; University Health Network and University of Toronto. Toronto, Canada
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Haloperidol
Ventajas
• Vida media larga (18 horas)
• POS
• Costo/efectivo
• Efectivo que ondansetrón y dexametasona
• Dosis bajas IV NO hay E2
• Guías recomiendan su uso tanto IV ó IM
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Haloperidol
Precauciones
• Cuidado en pacientes con QT prolongado
• No ha sido estudiado en niños
• Evidencia del beneficio en profilaxis, se menciona para rescate en las guías
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Clasificación del
riesgo PONV Apfel
Eberhart
Bajo Moderado Alto
No profilaxis
excepto riesgo
médico
Anestesia regional
No indicada
Reducción del riesgo de base
Considere terapia no farmacológica
Moderado Alto
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Moderado Alto
Dexametasona ó/y
Haloperidol Multimodal
Dexametasona y Haloperidol
+ Ondansetrón
Considere TIVA
Niños
Ondansetrón y
Dexametasona
Tratamiento
Falla: antiemético diferente a la profilaxis
No profilaxis: Ondansetrón
No repetir
< 6 horas
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