Vomiting can be defined as the forceful removal or ejection of the stomach`s content via the mouth and at times via the nose. It is clinically referred to as emesis and throwing up outside the medical circles (Kramer, et al, 2009). Vomiting is causes by many factors some of which may include gastritis, heightened intracranial pressure and brain tumors. The feeling that precedes vomiting is usually referred to as nausea (Drain &Odom-Forren, 2009). One characteristic of superiority in critical care is the extent of attentiveness to patient preferences (Kramer, et al, 2009). This is a concern which has been constantly raised by several patients who have agreed to surgical interventions as a procedure to prevent postoperative vomiting and nausea, which is highly feared and worrying (Jokela, et al, 2009). It is generally reported that about 75 million patients suffer from nausea and vomiting after surgery (Drain &Odom-Forren, 2009). Post operation vomiting can lead to fluid and electrolyte imbalances, esophageal ruptures, suture tensions, increased cranial pressure, bleeding and hypertension (Apfel, Kranke & Eberhart, 2004). Lifesaving surgical interventions reduce the period of time obtainable for preoperative evaluation (Drain &Odom-Forren, 2009; Neufeld & Newburn-Cook, 2008). Identification of critical patients, close monitoring by health care providers, and multidimensional interventions can significantly reduce the occurrence and intensity of vomiting and nausea subsequent to surgery (Apfel, Kranke & Eberhart, 2004). Post operation nausea and vomiting has been closely linked to administration of anesthetic medication from the early 1800s (Drain &Odom-Forren, 2009). Various definitions in literature vary in relation to the research study and the researchers’ description. The most widely used functional definition have been advanced by the American Society of PeriAnesthesia Nurses (ASPAN, 2006), which describe post operational nausea and vomiting that happens just within 24hrs post surgery.
Methodical reviews and meta-analysis have ben made use of to establish the prognosticators of post operative vomiting; however, knowledge about risk factors is deficient because understanding of the pathophysiology of nausea and vomiting beyond the cellular and molecular echelon is incomplete (Gan, 2006). The biological reactions to nausea and vomiting are not similar. The specific analysis of each one is critical to determining a patient’s response.
Each individual has a different capacity for stimulation of vomiting and nausea. Nausea and vomiting are guided by the central nervous system through the vomiting center in the brain and the chemoreceptor trigger zone (CTZ) at the bottom of the fourth ventricle (Steele & Carlson, 2007). Each feature of stimulation of these neural centers can be associated with processes that might take place in a patient during the use of anesthesia in surgical interventions. The brain can be unswervingly stimulated by the pharyngeal, mid brain afferent nerves, vagal, and the limbic system. The gag reflex can be aroused by mechanical exasperations such as removal or introduction of nasogastric tube, or a laryngeal airway mask, or an endotracheal tube in the course of perianesthesia period. Vagal arousal can also occur during intubation or suctioning that stimulates the carina. It is also noted that vagal afferent pathways can be aroused by poisonous substances in the stomach and by relaxation and contraction of the gastrointestinal region (Huether & McCance, 2008).
A shift in intracranial pressure generates midbrain stimulation, which is a primary aspect in neurological procedures. The limbic region that synthesizes emotions can be triggered by the learned response of preemptive vomiting. The CTZ has many receptor locations for chemical gesticulating and activation. The CTZ is not found in the blood-brain barrier, but rather at the postrema at the base of the fourth ventricle (Golembiewski & Tokumaru, 2006). The vomiting reflex starts three stages of physiological responses. These stages are characterized as post-ejection, ejection, and pre-ejections phases. Pre-ejection starts with the acetylcholine stimulation of the vagus nerve. Activation of the vagus nerve induces increased salivation, diaphoresis and reduce in gastric tone. Nausea is commonly a symptom of the pre-ejection stage. Ejection begins with abdominal and diaphragmatic tightening, proceeds with reflux of the stomach contents in to the esophagus, and ends with expulsion of the content from the mouth. The glottis shuts to avoid pulmonary aspiration. Post ejection appears to be the reduced feeling of nausea in the central nervous system (Apfel, Roewer & Korttila, 2002).
Nausea is a symptom related to vomiting. Because of it subjective feeling, nausea is perceived as a conscious cortical function. However the biological tract and chemical intermediaries that stimulate nausea are vaguer than those that induce vomiting (Flynn & Nemergut, 2006). Vestibular activation, odors, hormonal changes in pregnancy, and motion sickness are all risk factors associated with nausea. Generally in clinical practice and research vomiting and nausea are frequently treated as the same phenomenon. However, they are different and distinct features that can happen either independently or simultaneously. Nausea should be independently evaluated and researched from vomiting so that nausea can be adequately understood (Kenny, 2007). Nausea experienced in post operation patients might have varying risk factors in comparison to other patients such as motion sickness, and pregnant patients. There is no suitable instrument for evaluating the risk factors for nausea that has been validated. The general method of evaluating nausea is a modest 1 to 10 graphical analogue scale (Abrams, Pennington & Lammon, 2009).
Anesthetic/Operative Risk Factors
There are very many risk factors which are associated with post operational nausea and vomiting. The six main factors include hydration, body posture, and use of inhalers, surgical operation of organs, and use of opioids and discharge of cytokines (Deglin & Vallerand, 2009). Surgical transfer of organs by surgery and manual pressure disturb the enterochromaffin cells that outline the mucosa of the stomach tract. This disturbance promotes the discharge of serotonin and activates the parasympathetic nervous system through the vagus nerve (Apfel, Stoecklein &Lipfert, 2005).
Brain and spinal surgery are usually associated with high occurrences of emetogenesis. According to Flynn and Nemergut (2006) it was observed that post operative vomiting was higher in endonasal transphenoidal surgery especially where cerebral fluid undercurrents were influenced by an intraoperative lumbar outlet or fat implants for spinal fluid seepages (Conway, 2009). Nausea and vomiting are also closely associated with side effects of medication. The four basic forms of medicine that are mainly linked with nausea and vomiting would include; inhalers, anti-cancer medication, estrogen preparations and opioids (Lambert, Wakim & Lambert, 2009). Inhalation medicine is commonly known as the trigger for post operational nausea and vomiting. They reduce the level of consciousness by reducing the achievement potential breadth and frequency of the central nervous system. This disturbance of regular neural electrical impulse can activate the CTZ and vomiting center (Magner, McCaul, Cannon, Gardiner & Buggy, 2004).
There are two additional factors that affect a patient’s risk of post operational nausea and vomiting which include gender and smoking. In comparison to men, women have a higher predisposition for vomiting that is observed after puberty. Women are known to vomit about two to three times more than their male counterparts of the same age (Murphy, Hooper, Sullivan, Clifford & Apfel, 2006). It is also noted that vomiting also increases with the use of birth control medication and also during pregnancy. These changes are as a result of various endocrine mechanisms related with child bearing. It is also noted that no smokers generally metabolize anesthetic medication much slower than their smoking counterparts. Smoking is said to block or inhibit liver enzymes that facilitate the metabolism and discharge of anesthetics (Cotton, Rowell, Hood & Pellegrini, 2007).
During lengthy surgical procedures patient might be unable to readjust their body posture due to the influence of anesthesia and neuromuscular blockage. This eventually results in blood pooling and feeling of dizziness that can activate vestibular disequilibrium. This imbalance may lead to further stimulation of the CTZ by the vestibular nerve, substituting as an additional activation of the post operational nausea and vomiting (McCaffrey, 2007).
Interventions and Guidelines
According to the ASPAN, it has documented evidence based frameworks that provide two divergent algorithms as a practical guideline of care for patients potentially at risk of post operational nausea and vomiting (Lee & LTY, 2009). The first algorithm is mainly used in instances where surgery is elective and there may be no adequate time to obtain history of the patient for classification of risk factors. It is important to note that the category of risk dictates the choices of prophylactic pharmacology intrusions that may reduce the occurrence of post operational nausea and vomiting (Collins, 2011).
The second algorithm may be used when preoperative evaluation is truncated due to the need of immediate surgical intrusion to save the life of the patient. Here emphasis is on early evaluation and monitoring of post operational nausea and vomiting and the significance of the rescue antiemetic treatment. There are a lot of things that need to be completed when a patient has ben transferred to the intensive care unit after a life saving surgery. However, a major issue of concern is what is the risk attributed to the patient in relation to post operational nausea and vomiting; and what antiemetic prophylaxis has been instituted. Every time the patient is evaluated for pain, he or she must be also evaluated for nausea and vomiting (Collins, 2011).
Each acute health care institution makes multidisciplinary choices on which antiemetic treatment will be used in practice. These choices are mostly influenced by cost, previous experience, preferences, current evidence and the consequences of post operational nausea and vomiting on the eventual patient outcomes. The extent to which any intervention can be effective basically depends on individual patients responses. Different people have different distribution, absorption, metabolism and excretion of anesthetic medication. These variations in pharmacokinetics are as a result of genetic factors such as gender, weight and contemporary diseases (McCaffrey, 2007). Timing of the dispensation of antiemetic treatment is also critical. Medication agents such as ondansetron, an adversary of serotonin receptors are most applicable when the dose is issued at the conclusion of the surgery (Apfel, Kranke & Eberhart, 2004).
PONV is of critical concern to many patients; successful management can sufficiently encourage better patient outcomes and comfort. Determining the right treatment requires deliberation with the patient and patient’s next of kin about the specific risk factors and predilections and consultations among the facilitators of care traversing the perianesthesia field. When health care decisions are made basing on the patients and the patients next of kin`s concerns, collaboration results in optimal outcomes.
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