Post-Operative Nausea and Vomiting (PONV) Risk Factors

Surgical Procedures with High Risk for PONV

Certain surgical procedures are associated with a higher risk of PONV. The highest-risk procedures include:

• Cholecystectomy (gallbladder removal)
• Gynecological surgeries (e.g., laparoscopic surgeries)
• Laparoscopic surgeries (general)
• Breast surgeries (such as mastectomy)
• Otorhinolaryngological surgeries (e.g., ear, nose, and throat surgeries)
• Strabismus surgery (eye muscle surgery)

Patient Characteristics Associated with Increased PONV Risk

Certain patient characteristics are also associated with a higher risk of developing PONV:

• Female gender
• Non-smoking status
• History of PONV or motion sickness
• Younger age
• Use of volatile anesthetics during surgery
• Use of postoperative opioids

Guidelines and Evidence Basis

The information provided is based on guidelines from the American Society of Anesthesiologists (ASA) and other peer-reviewed studies:

• Apfel CC, et al. "A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers." Anesthesiology 1999; 91:693-700.
• Gan TJ, et al. "Consensus guidelines for the management of postoperative nausea and vomiting." Anesthesia & Analgesia 2014; 118:85-113.

These resources provide a comprehensive overview of risk factors based on clinical trials and research data.

Literature on Dose Rounding in Electronic Health Records

The integration of dose rounding in electronic health records (EHRs) is an important strategy discussed in the literature to enhance the safety and affordability of chemotherapy and other high-cost medications. Here are some key points:

1. Objective of Dose Rounding

Dose rounding aims to standardize the dosages of medications to the nearest standard vial size or dose, minimizing wastage and potential for error. This approach is particularly relevant in the administration of expensive medications such as chemotherapy drugs.

2. Benefits of Dose Rounding

• Cost Reduction: By rounding doses to available vial sizes, healthcare providers can significantly reduce the cost associated with unused medication.
• Reduced Medication Errors: Standardizing doses can also decrease the likelihood of dosing errors, enhancing patient safety.
• Inventory Management: Simplifies inventory control by reducing the need for multiple vial sizes.

3. Implementation in EHRs

Studies emphasize the importance of incorporating dose rounding algorithms and protocols directly into EHR systems to automate the process and ensure consistent application across healthcare settings. This requires collaboration between pharmacists, clinicians, and IT specialists.

4. Challenges and Considerations

• Patient Specificity: While rounding is beneficial, individual patient needs and specific dosing requirements must be considered to avoid compromising therapeutic efficacy.
• Clinical Acceptance: Encouraging clinicians to adopt dose rounding practices involves education and demonstrating the benefits through evidence-based outcomes.

5. Conclusion

Literature suggests that dose rounding incorporated into EHRs can streamline medication administration processes and reduce both costs and errors. However, careful planning and execution are required to balance cost-efficiency with personalized patient care.

Treatment for Candidemia

Recommended Treatments

Candidemia, a bloodstream infection caused by Candida species, requires prompt and effective antifungal treatment. The choice of antifungal agent depends on the specific circumstances of the infection, including the patient's clinical status, the species of Candida involved, and any prior exposure to antifungal drugs.

First-line Treatment

• Echinocandins: Generally recommended as the first-line treatment for most patients with candidemia.
• Examples include caspofungin, micafungin, and anidulafungin.

When to Use Azoles

• Fluconazole: May be considered in specific situations, such as:
• When the Candida species is known to be susceptible.
• For stable, non-critically ill patients without recent azole exposure.
• In cases where long-term oral therapy is preferred after initial echinocandin treatment.

Considerations for Antifungal Selection

• The choice between echinocandins and azoles should be guided by local antifungal susceptibility patterns and individual patient factors.
• Prior exposure to azoles may necessitate the use of echinocandins to reduce the risk of resistance.
• In cases of Candida glabrata or Candida krusei infections, echinocandins are preferred due to potential azole resistance.

Conclusion

The management of candidemia requires careful consideration of the patient's condition, the Candida species involved, and the antifungal susceptibility profile. Consultation with an infectious disease specialist is often advisable to tailor the treatment approach to the individual patient's needs.

Contrast Administration Guidelines

IV Contrast

• Iodinated Contrast for CT Scans:
  • Dosage varies based on specific agent and patient's weight (mL/kg).
  • Caution in patients with impaired kidney function.
• Gadolinium-based Contrast for MRIs:
  • Dosage based on body weight and specific agent.
  • Consider risks in patients with renal impairment.

Oral Contrast

Used for gastrointestinal imaging and generally safer with fewer systemic effects.

General Guidelines

• Renal Function Monitoring: Assess kidney function before administration.
• Hydration: Ensure adequate hydration before and after the procedure.
• Time Intervals: Allow 24-48 hours between administrations, depending on renal function and contrast type.
• Consultation with Specialists: Consult radiology and nephrology in complex cases.

Evidence for Epidural Dexmedetomidine in Laboring Patients

Introduction

Dexmedetomidine is a highly selective alpha-2 adrenergic agonist with sedative, anxiolytic, and analgesic properties. Its use in the epidural space for labor analgesia is of growing interest due to its potential benefits in enhancing analgesia and reducing required doses of other analgesics.

Clinical Evidence

• Enhancement of Analgesia: Studies have shown that when dexmedetomidine is added to epidural analgesia, it can enhance the analgesic effect, allowing for reduced doses of local anesthetics and opioids, potentially leading to fewer side effects.
• Reduction in Opioid Use: The addition of dexmedetomidine may decrease the need for opioids, which in turn can reduce opioid-related side effects such as nausea and respiratory depression.
• Improved Patient Satisfaction: Some trials have reported higher patient satisfaction scores due to better pain control and reduced side effects when dexmedetomidine is used.

Safety and Side Effects

• Hemodynamic Stability: While generally well-tolerated, dexmedetomidine can cause bradycardia and hypotension, necessitating careful monitoring.
• Respiratory Effects: Unlike opioids, dexmedetomidine does not significantly depress respiration, making it a potentially safer option for labor analgesia.

Conclusion

While early studies are promising, more extensive and well-designed clinical trials are necessary to fully establish the safety and efficacy of epidural dexmedetomidine in laboring patients. Its potential benefits make it an interesting prospect for enhancing labor analgesia with fewer side effects compared to traditional methods.

References

For further reading, please refer to recent publications and clinical trials on the subject in peer-reviewed medical journals.