Managing Postoperative

Complications Related to Anesthesia

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Please be advised that this activity is being audio recorded for archival purposes and, in some
cases, for repurposing of the content for enduring materials.

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 Managing Postoperative Complications
Related to Anesthesia
AGENDA
6:15 a.m. – 6:45 a.m. Registration and Breakfast

6:45 a.m. – 6:50 a.m. Welcome – Introductory Remarks

Tricia Meyer, Pharm.D., M.S., FASHP

6:50 a.m. – 7:40 a.m. Managing Postoperative Complications Related to

Anesthesia

7:40 a.m. – 7:45 a.m. Questions & Answers

FACULTY
Tricia Meyer, Pharm.D., M.S., FASHP
Senior Director – Department of Pharmacy
Scott & White Healthcare
Temple, Texas
Associate Professor
Department of Anesthesiology
The Texas A&M Health Science Center - College of Medicine
Temple, Texas
Associate Professor
Irma Lerma Rangel College of Pharmacy
Texas A&M Health Science Center
Kingsville, Texas

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 Managing Postoperative Complications
Related to Anesthesia
DISCLOSURE STATEMENT
In accordance with the Accreditation Council for Continuing Medical Education’s
Standards for Commercial Support and the Accreditation Council for Pharmacy
Education’s Guidelines for Standards for Commercial Support, ASHP Advantage
requires that all individuals involved in the development of activity content disclose their
relevant financial relationships. A person has a relevant financial relationship if the
individual or his or her spouse/partner has a financial relationship (e.g., employee,
consultant, research grant recipient, speakers bureau, or stockholder) in any amount
occurring in the last 12 months with a commercial interest whose products or services
may be discussed in the educational activity content over which the individual has
control. The existence of these relationships is provided for the information of
participants and should not be assumed to have an adverse impact on presentations.

All faculty and planners for ASHP Advantage education activities are qualified and
selected by ASHP Advantage and required to disclose any relevant financial
relationships with commercial interests. ASHP Advantage identifies and resolves
conflicts of interest prior to an individual’s participation in development of content for an
educational activity.

The faculty and planners report the following relationships:

Tricia Meyer, Pharm.D., M.S., FASHP

Dr. Meyer declares that Scott and White is the recipient of a multisite grant from
Merck.

Peggy S. Bickham, Pharm.D.

Dr. Bickham declares that she has no relationships pertinent to this activity.

Erika Thomas, M.B.A., B.S.Pharm.

Ms. Thomas declares that she has no relationships pertinent to this activity.

Kristi N. Hofer, Pharm.D.

Dr. Hofer declares that she has no relationships pertinent to this activity.

Susan R. Dombrowski, M.S., B.S.Pharm.

Ms. Dombrowski declares that she has no relationships pertinent to this activity.

ASHP staff has no relevant financial relationships to disclose.

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 Managing Postoperative Complications
Related to Anesthesia
ACTIVITY OVERVIEW
The Centers for Disease Control and Prevention estimates that there are 48 million
inpatient surgical procedures each year in the U.S. Over the last 25 years, anesthesia
has become significantly safer resulting in a dramatic decrease in anesthesia-related
mortality rates. The American Society of Anesthesiologists estimates that an individual is
approximately 40 times more likely to be struck by lightning than he or she is to die from
anesthesia-related complications. However, anesthesia and anesthetic drugs can cause
adverse events in some surgical patients. This symposium will focus on selected
postoperative complications related to anesthesia drugs.

Whether anesthetic drugs are administered in the hospital setting or in an ambulatory

surgery center, pharmacists should be aware of the risks in order to assist in managing
anesthesia drug-related complications. This symposium will highlight recommendations
for the management of common complications of anesthesia, such as postoperative
nausea and vomiting, neuromuscular residual paralysis, and other adverse events,
emphasizing the important role of pharmacists in perioperative patient care.

ACTIVITY OBJECTIVES
At the conclusion of this application-based educational activity, participants should be able to
 Describe common anesthesia-related complications that occur in the early
postoperative phase.
 Discuss pharmacologic strategies for managing postoperative complications
related to anesthesia drugs.
 Apply clinical evidence and emerging therapy for the management of a
postoperative patient with complications related to anesthesia drugs.

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 Managing Postoperative Complications
Related to Anesthesia
CONTINUING EDUCATION ACCREDITATION
The American Society of Health-System Pharmacists is accredited by
the Accreditation Council for Pharmacy Education as a provider of
continuing pharmacy education. This activity provides 1.0 hour (0.1
CEU) of continuing pharmacy education credit (ACPE activity #0204-
0000-12-439-L01-P).

Attendees must complete a Continuing Pharmacy Education Request online and may
immediately print their official statements of continuing pharmacy education credit at the
ASHP CE Center at http://ce.ashp.org following the activity.

Complete instructions for receiving your statement of continuing pharmacy education

online are found at the front of the CE in the Mornings handout booklet. Be sure to
record the SESSION CODE beginning with “A” announced during the activity.

Your educational opportunities

extend beyond today’s symposium…

A live webinar to be conducted February 28, 2013, where Tricia Meyer, Pharm.D.,
M.S., FASHP will explore issues raised by participant questions in today’s symposium
(1 hour of CPE).

E-Newsletters featuring tips for incorporating information from this symposium into
practice, as well as updates on emerging information.

Web-based activity based on today’s live symposium (1 hour of CPE, but please
note that individuals who claim CPE credit for the live symposium are ineligible to
claim credit for the web-based activity).

For more information and to sign up

to receive e-mail updates, visit

www.cemornings.com

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 Managing Postoperative Complications
Related to Anesthesia
Tricia A. Meyer, M.S., Pharm.D., FASHP
Senior Director – Department of Pharmacy
Scott & White Healthcare
Temple, Texas
Associate Professor
Department of Anesthesiology
The Texas A&M Health Science Center - College of Medicine
Temple, Texas
Associate Professor
Irma Lerma Rangel College of Pharmacy
Texas A&M Health Science Center
Kingsville, Texas

Tricia A. Meyer, M.S., Pharm.D., FASHP, is Senior Director – Department of Pharmacy

at Scott and White Healthcare in Temple, Texas. Dr. Meyer is also Associate Professor
of Anesthesiology for the Department of Anesthesiology at the Texas A&M University
College of Medicine at the Temple campus and Adjunct Associate Professor of
Pharmacy Practice at the Texas A&M Irma Lerma Rangel College of Pharmacy.

Dr. Meyer earned her Bachelor of Science degree in pharmacy with honors at the
University of Texas in Austin, Texas, Master of Science degree from Texas State
University in San Marcos, Texas, and Doctor of Pharmacy degree from Shenandoah
University in Winchester, Virginia.

Dr. Meyer has published and presented extensively on the topics of perioperative
pharmacy, anesthesia, and post-operative nausea, and vomiting. She is a member of
the American Society of Health-System Pharmacists (ASHP) and was recognized as a
fellow of ASHP in 2001. She is also a member of the Texas Society of Health-System
Pharmacists and the Anesthesia Patient Safety Foundation.

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Managing Postoperative Complications 
Related To Anesthesia
Tricia Meyer, Pharm.D., M.S., FASHP
Senior Director, Department of Pharmacy
Scott & White Healthcare, Temple, Texas
Associate Professor , Department of Anesthesiology
The Texas A&M Health Science Center ‐ College of Medicine
Temple, Texas

Learning Objectives
• Describe common anesthesia-related
complications that occur in the early
postoperative phase.
• Discuss pharmacologic strategies for managing
postoperative complications related to
anesthesia drugs.
• Apply clinical evidence and emerging therapy for
the management of a postoperative patient with
complications related to anesthesia drugs.

Surgical Stats
• 46 million inpatient procedures in 2006
• 53 million outpatient surgical and non‐surgical 
procedures for ambulatory surgery visits in U.S.
• 24 million surgeries in U.S. involve general 
anesthesia 
• 6% postoperative complication for non‐cardiac 
surgeries in U.S.
• >30% postoperative complications for high risk 
surgeries in U.S.
Cullen. 2006 Ambulatory Surgery in the U.S. National Health Statistics Report. 2009.;
Kassin et al.JACS. 2012;215(3):322-330; Bratzler.CID.2006:43;322-30; National Hospital Discharge Survey: 2006. summary.
National Center for Health Statistics. Vital Health Stat 13 (168).2010.

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Types of Postoperative Complications
• Complications common to any procedure
– Major and minor complications
• Complications common to specific 
p
procedure
– Major and minor complications
• Anesthesia related complications
– Major and minor complications

Complications can be immediate, early in 
postoperative period or delayed

Postoperative Surgical Complications
• Wound complications
– dehiscence, infection, hematoma, bleeding
• Cardiovascular
– hypertension, arrhythmias, hemorrhage, shock, MI, DVT
• Renal
– urinary retention, acute renal failure
• Hepatic
• Gastrointestinal
– ileus
• Cerebral
– Seizure, stroke
• Nerve injury
• Pulmonary

Postoperative Anesthesia 
Complications
• Bronchospasm
• Laryngospasm
• Airway obstruction
• Delayed emergence
• Aspiration of gastric contents
• Residual paralysis
• Cognitive dysfunction
• Vision loss or blindness
• Drug‐induced respiratory depression

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 Other Postoperative Complications

• Pain
• Shivering
• Delirium/Agitation
• Nausea, vomiting and retching
• Sore throat
• Fever
• General‐headache, dizziness, drowsiness

Agents Used in General Anesthesia
• Induction agents  (e.g., propofol)
• Analgesics  (e.g., fentanyl, sufentanil )
• Neuromuscular Blocking Agents  (e.g., rocuronium, 
vecuronium, cisatracurium, pancuronium)

• Inhalational Agents  (e.g., desflurane, sevoflurane, isoflurane)
• Antagonism of  non‐depolarizing NMBA*  (e.g., 
neostigmine, edrophonium, pyridostigmine) 

• Antiemetics  (e.g., ondansetron, dexamethasone, droperidol, 
promethazine, aprepitant)
*MNBA is neuromuscular blocking agent

Surgical Case for the Day
• M.S. is a 81 year‐old female 
• Scheduled for inpatient surgery colon resection (open 
abdominal), scheduled for 4 hrs. OR time  
• Wt. = 98 Kg,  Ht. = 5’4”
• ASA  Physical Class = 2/5
• Allergies: penicillin, cephalosporin
Allergies: penicillin cephalosporin
• PMH: PONV, motion sickness on last cruise, asthma, 
non‐smoker
• PSH: Mastectomy;  pt. stated “difficult to wake up”
• General anesthesia: propofol,  desflurane; 
pancuronium, fentanyl, antiemetics‐TBD

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 Neuromuscular Blocking 
Agents and Residual Paralysis

Use of Neuromuscular Blocking Agents 
During Surgery
• Total muscle relaxation is needed to help achieve 
best operating conditions/visual field 
• Adds to safety of the patient during delicate or 
critical surgeries
• Additional use of NMBA for muscle relaxation for 
endotracheal intubation
• 100,000 annually patients suffer respiratory 
complications after surgery due to residual paralysis
• Lack of standard for monitoring post‐surgery 
weakness
Marcus, A. Clinical Anesthesiology. Residual Paralysis: The problem that won’t
go away. Anesthesiology News. July 2012; Volume38:7

Residual Neuromuscular 
Blockade/Paralysis
• Incomplete recovery from non‐depolarizing 
neuromuscular blocking agents; prolonged 
neuromuscular blockade in recovery
• Frequency of residual paralysis ranges from 2‐64%
• Most clinical trials examining postoperative residual 
paralysis now use a train‐of‐four (TOF) ratio <0.9 to 
define incomplete neuromuscular recovery
• TOF‐ratio >0.9 indicates sufficient recovery of 
neuromuscular transmission for awakening the patient 
and ensuring safe tracheal extubation
Murphy. A&A.2010.111;1;120-8 Naguib.BJA.2007;98:302
Murphy. Minerva Anestesiol.2006;72:97-109.

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 Current Reversal Agents
(edrophonium, neostigmine, pyridostigmine)
• Recovery rate is dependent on: depth of blockade; 
which reversal agent and dose used; rate of 
spontaneous recovery; concentration of inhaled 
anesthetic
• Rapidity of reversal: edrophonium >neostigmine 
>pyridostigmine  however edrophonium is not as 
effective  in profound block
• Use of glycopyrrolate and atropine to block 
muscarinic effect/cardiovascular effects
• Neostigmine may take 10‐15 min. to achieve 
complete neuromuscular recovery
Miller’s Anesthesia. 7th Edition.2010.Chapter 29

Adverse effects of residual neuromuscular 
blockade in awake volunteers and surgical patients

• Impaired airway protective reflexes
• Upper airway obstruction
• Impaired hypoxic ventilatory response
• Postoperative hypoxemia
Postoperative hypoxemia
• Symptoms and signs of profound muscle weakness
• Swallowing disrupted; increased risk  aspiration
• Delay in discharge

Murphy.AnesthAnalg.2005;100:1840; Sorgenfrei.Anesthesiology.2006;104:667; Murphy. Minerva

Anestesiol.2006;72:97; Eriksson.Anesthesiology.2003;98:1037

Relationship of the Train‐of‐four to Clinical 
Signs and Symptoms of Residual Paralysis in 
Awake Volunteers

Clinical Signs/ TOF 0.7 TOF 0.9

Symptoms
Vision Diplopia Significant visual 
disturbances

Clench teeth tightly Weak opposition to  Opposition to tongue 

tongue depressor depressor
Head/Leg lift Sustained Sustained

Grip strength 59% of control 83% of control

Kopman.Anesthesiology.1997;86:765.

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 Incidence of Postoperative Residual Bock in Recovery  
after Intermediate‐acting Neuromuscular Blocking Drugs

Residual block Vecuronium  Atracurium  Rocuronium 

Total
TOFR < 0.8 n=50 n=50 n=48
Overall‐postoperative  52% 64% 52% 39%
residual paralysis 

Unable to open eyes 29 (20%) 10 (20%) 12 (24%) 7 (15%)

Unable protrude tongue 41 (28%) 13 (26%) 17 (34% 11 (23%)

Unable lift head for 5sec 90 (61%) 35 (70%) 29 (58%) 26 (54%)

Unable to  lift leg for 5  91 (62%) 33 (66%) 32 (64%) 26 (54%)

sec

Unable to grip hand 101 (68%) 41 (82%) 34 (68%) 26 (54%)

Unable to swallow 32 (22%) 12 (24%) 13 (26%) 7 (15%)

Hayes.Anaesthesia.2001;56:312-18.

Residual Paralysis in PACU after a Single Intubating  See page 27 for enlarged view

Dose of Nondepolarizing Muscle Relaxant of 
Intermediate Duration
Residual paralysis rate (%) between administration of muscle relaxant and arrival 
to PACU

Debaene. Anesthesiology.2003.;98:1042.

Residual Paralysis at the Time of 
Tracheal Extubation
• “Complete recovery of neuromuscular function should be 
present at the time of tracheal extubation to reduce the 
risk of adverse respiratory event.” 
• “Respiratory and pharyngeal function do not normalize 
until  TOF ratios of 0.8‐1.0.   These findings suggest that 
removal of endotracheal tube in the presence of minimal 
levels of residual block can potentially contribute to 
adverse outcomes.”
• “Period of vulnerability” between tracheal extubation and 
complete recovery of neuromuscular function, …..  leading 
to airway obstruction, aspiration, and ventilatory 
depression.

Murphy. Anesth Analg.2005;100:1840-5.

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 Recovery from Neuromuscular Blockade: 
A Survey of Practice
Perceptions of TOF ratio required for safe extubation

TOF ratio (%) Respondents (n) Respondents

(%)
100% 44 8.2%
>90% 110 20.6%
80‐85% 68 12.7%
75% 122 22.8%
70% 55 10.3%
50‐69% 23 4.3%
<50% 10 1.8%
0% 89 16.6%
Other response 13 2.6%

Grayling.Anaesthesia.2007;62:806-809.

Muscle Relaxants
• “The most important problem in current clinical use of 
muscle relaxants is failure to achieve adequate recovery” 
from their effect 1

• “Omitting pharmacologic reversal is a common practice, 
and the clear consequence is inadequate recovery of 
neuromuscular function…. 1

• “….probably underestimates the true incidence of 
inadequate recovery of neuromuscular function.” 1

• “Given that postoperative residual curarization is a 
potentially preventable patient safety problem, it is 
important to find ways to reduce its incidence.”2
Caldwell, J.ASA Newsletter.2003;67(9.);Naguib.BJA.2007;98;302‐16.

Polling Question…
M.S. may have a greater chance of having 
residual paralysis due to 

Female sex

Use of long acting NMBA

Cephalosporin allergy

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 Antiemetics and Postoperative 
Antiemetics and Postoperative
Nausea and Vomiting

PONV: An Undesirable 
Consequence of Surgery
Patients rank vomiting as the most undesirable outcome, even more undesirable than pain.

Patient Ranking
Rank Postoperative Anesthesia Outcomes
1 Vomiting
2 Gagging on endotracheal tube
3 Incisional pain
4 Nausea
5 Recall without pain
6 Residual weakness
7 Shivering
8 Sore throat N=101; F-test <0.01.
9 Somnolence

Adapted from Macario A et al. Which clinical anesthesia outcomes are important to avoid?
The perspective of patients. Anesth Analg. 1999;89:652–658.

Post‐discharge PONV (PDNV) 
40%
ence of PONV

35% 31.2%
29.5%
30%

25%
Incide

20%
16.1%
15%

10%

5%

0%
Recovery room <48 h >48 h to 5 d
post discharge post discharge

Carroll NV, et al. Anesth Analg. 1995;80:903–909.

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 Complications of Postoperative 
Nausea and Vomiting
• Aspirations
• Suture dehiscence
• Esophageal Rupture
• Bilateral pneumothoraxes
• Delays
• Unexpected admission
• Annual cost estimated several $100 Million

Gan TJ et al. Anesth Analg. 2007; 105:1615-28.

Risk Factors For PONV In Adults See page 28 for enlarged view

*
Evidence Risk Factors
Positive overall Female sex
History of PONV or Motion Sickness
Non‐smoking
Younger age
General vs. regional anesthesia (A1)
Use of volatile anesthetics and nitrous oxide (A1)
Postoperative opioids (A1)
Duration of anesthesia
Conflicting  ASA physical status
Type of surgery (cholecystectomy, laparoscopic, gynecological)
Menstrual cycle
Level of anesthetist’s experience
Muscle relaxant antagonists (A2)
Disproven or of limited  BMI
clinical relevance Anxiety 
Nasogastric tube (A1)
Supplemental oxygen (A1)
Perioperative fasting (A2)
Migraine

Gan TJ et al. Anesth Analg. In manuscript preparation.

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 Risk Score in Children
Risk Factors Points
80
Surgery > 30 1

sk (%)
min.
60
Age > 3 1

POV Ris
years
40
Strabismus 1
surgery
20
History of 1
POV or
0
PONV in 0 1 2 3 4
relatives Number of Risk Factors
Sum = 0...4

Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the
management of postoperative nausea and vomiting. A&A. 2007;105:1615-28.

Postdischarge Nausea and 
Vomiting (PDNV) Adult Risk Score
Risk Factors Points

Female sex 1

History of PONV  1

Age <50 years 1

Use of opioids in the  1
PACU

Nausea in the PACU 1

Sum 0…5

Apfel. Who is at risk for PDNV after ambulatory surgery? Anesthesiology. 2012;117(3):475-86.

Reduce baseline risk
1. Avoidance of general anesthesia by the use of 
regional anesthesia  
2. Use of propofol for induction and maintenance of 
anesthesia 
3. Avoidance of nitrous oxide  
4. Avoidance of volatile anesthetics  
5. Minimization of intraoperative and postoperative 
opioids 
6. Adequate hydration 

Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the
management of postoperative nausea and vomiting. A&A. 2007;105:1615-28.

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 Families of Antiemetic Drugs

• Phenothiazines (Dopamine D2 receptor) • Antihistamines (Histamine)

 Chlorpromazine   Dimenhydrinate 
 Prochlorperazine  Hydroxyzine
 Promethazine  Diphenhydrinate
• Butyrophenones                                        • 5‐HT3 antagonists (Serotonin)
(Dopamine D2 receptor)  Dolasetron
 Droperidol 
D id l  Granisetron
 Haloperidol  Ondansetron
• Benzamides   Palonosetron
(Dopamine D2 receptor) • Steroids  (Receptor is unclear)
 Metoclopramide  Dexamethasone
• Anticholinergics (Muscarinic) • NK1‐receptor antagonists
 Scopolamine  Aprepitant

Pathophysiology of PONV
Antagonist
5-HT3 Promethazine Atropine Droperidol

Agonist
5-HT3 Histamine Muscarinic Dopamine (D2)
Nitrogen mustard
Receptor site Cisplatin
Digoxin glycoside
Chemoreceptor Trigger Zone
NK1 A
Area P t
Postrema Opioid analgesics
Substance P
Vestibular portion
of VIIIth nerve
CB1 Emetic
Center
?
Cannabinoids
N2O
?
Parvicellular ?
GI tract distension
reticular Mediastinum Higher centers
formation (vision, taste)
Pharynx
(Adapted) Watcha MF, White PF. Anesthesiology. 1992;77:162-184.

5HT‐3 Receptor Antagonists IV
• Ondansetron 4mg, give at end of surgery; cost=¢
• Granisetron 0.3mg‐1 mg, give at end of surgery; cost=<$
• Dolasetron 12.5mg, give at end of surgery; cost=$$$
• Palonosetron 0.075mg (not marketed for PONV); cost=$$$$$$$$$
• More effective for vomiting rather than nausea
• Used for prevention and treatment
Used for prevention and treatment 
• Side effects‐HA, constipation
• Recent FDA warning for ondansetron:  Avoid use in patients with 
congenital long QT syndrome ; ECG monitoring ‐ electrolyte 
abnormalities, congestive heart failure, bradyarrhythmias, or  
patients taking  medications that can lead to QT prolongation.  
Dolasetron and granisetron carry similar  concerns
Palonosetron has not shown QT prolongation concerns

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 Anticholinergic Agents
• Scopolamine transdermal patch‐1.5 mg; one patch 
4hrs prior to surgery; duration 24 hrs; cost=$$
• Do not use in children; caution in elderly
• Do not cut patch
• Wash hands after handling
• Contraindicated in closed angle glaucoma
• Common side effects: sedation, dry mouth, visual 
disturbances

Butyrophenones IV
Droperidol ‐ 0.625mg‐1.25mg; given at end of surgery; cost=¢ 
• Efficacy with nausea
• Potential for serious proarrhythmic effects and death:
– Reserve for treatment of patients who failed other treatments
– 12‐lead ECG prior to administration
12 lead ECG prior to administration
– Continue ECG monitoring for 2‐3 hours after administering 
droperidol
Haloperidol ‐ 0.5mg‐2mg; cost=¢
• Used more in treatment
• Similar concerns of CV effects to droperidol (no FDA boxed 
warning)

Phenothiazines IV
Prochlorperazine ‐ 5‐10 mg; unavailable supply since 7‐ 2011
Promethazine ‐ 6.25mg‐25mg; start with 6.25 mg dose, 25 mg 
associated with significant side effects; cost=¢
FDA boxed warning‐risk of serious tissue 
damage:
• Dilute drug
• Slow administration
• Use large patent veins
• Educate patient about signs of extravasation

• Contraindicated in children < 2 yrs
• Use lowest dose possible with elderly 

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 Dexamethasone IV
• Dexamethasone ‐ 4mg given at induction; cost=¢
• Mechanism of action is unclear
• Duration of action – up to 24hrs.
• Most common side effect‐ vaginal or anal irritation 
or itching
– Administer drug slowly over 5‐10 min.
– Administer after induction
Recent reports in literature
– Increase in blood glucose levels
– Concerns of post op infection
– Tumor lysis syndrome
– Bleeding post tonsillectomy

Substance P/NK1 receptor antagonist
• Aprepitant 40mg oral and given 3 hrs prior to 
induction
• Indicated for prevention of postoperative nausea 
and vomiting.
• Drug interactions:
g
– warfarin‐ patient to have INR post surgery; 
– oral contraceptives‐patient to use other forms of birth 
control for 1 month
• $$$$$$$$$

Results of Factorial Trial of 6 
Interventions
Number of Antiemetics Incidence of PONV

None 52%
One 37%
Two 28%
Three 22%
There were no significant differences between
the antiemetics or pairs of antiemetics.
26% reduction in relative risk for each additional
antiemetic used.
Apfel CC. NEJM 2004;350(24):2441.

22
 Algorithm for Management of PONV See page 29 for enlarged view

Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the
management of postoperative nausea and vomiting. A&A. 2007;105:1615-28.

KEY

See page 30 for enlarged view

Aprepitant=A
(HA, Elevated liver enzymes)
Ondansetron=O
(HA, Lightheadedness, Elevated liver enzymes,
A,D,O,G,S,Dr,P,Pa,Pc,Dm,Dp
Constipation, QT prolongation)
Dm,S Dp
Dolasetron=D
(HA, Lightheadedness, Elevated liver enzymes,
QT prolongation, Diarrhea)
Droperidol=Dr
S,Dm,Dp
(Sedation, dizziness, anxiety, hypotension, EPS,
QT prolongation, and Torsade de pointes)
Granisetron=G
(HA, Lightheadedness, Elevated liver enzymes, D, O, Dr, G,
Constipation) M,Pa,Pc, P
Dexamethasone=Dx
P
(Vaginal itching or anal irritation with IV bolus,
*Hyperglycemia (gluconeogenesis in liver))
Metoclopramide=M
(Sedation, Hypotension, EPS)
A ,O,
O D,
D
Promethazine=P
G,S,Dx*
(Sedation, Hypotension, EPS, Possible severe
tissue irritation) S S
Scopolamine Patch=S
(Sedation, Dry mouth, Visual disturbances; CNS
effects in elderly patients, Renal or hepatic Dx
impairment) O, G, D,Pa,Dm,Dp
Palonosetron=Pa
(HA, Constipation, QT prolongation, Bradycardia)
Prochlorperazine=Pc
(Sedation, Hypotension, EPS)
Dimenhydrinate=Dm
(Sedation, dry mouth, blurred Antiemetic Man
vision, dizziness, urinary retention)
Diphenhydramine=Dp Common side effects with traditional antiemetic
(Sedation, dry mouth, blurred
vision, dizziness, urinary retention) medications

Polling Question…
What are the risk factors for PONV for the 
surgery patient (M.S.)? 

Female sex

History of PONV/Motion Sickness

Non‐smoker

23
 Postoperative Opioid‐Induced 
Respiratory Depression
(POIRD) 
(POIRD)

Opioid Use 
• Opioid analgesia is primary intervention for pain in 
hospitalized patients
• Opioid side effects‐nausea/vomiting, urinary 
retention, pruritus, prolonged postop ileus
• Main hazards of opioids is respiratory depression
• 50% of postoperative respiratory depression involved 
opioids
• Severe respiratory depression‐breathing rates of 8‐10 
breaths/min
• Risk of opioid‐induced respiratory depression in 
postop patients is greatest in first 24 hrs after surgery
• Respiratory depression occurs most frequently 
between hours of 2300‐0700 when patients are 
sleeping
Jarzyna et al.Pain Management Nursing.2011;12(3):118-45

Opioid Induced Respiratory 
Depression Risk Factors
• Age >55yrs
• Obesity
• Untreated sleep apnea & history snoring
• Neck circumference >17.5”
• Preexisitng pulmonary/cardiac disease
• Smoker > 20pack‐years
• P l
Prolonged surgery
d
• Thoracic or other large incisions that interfere with ventilation
• Concomitant administration of other sedating drugs
• Patients with prior naloxone administration for respiratory 
depression are at risk for repeated respiratory depression
• ↑ opioid requirement
• Major organ failure
• Dependent functional status
Jarzyna et al. Pain Management Nursing.2011;12(3):118-45

24
 Naloxone
– Introduced in late 1960’s
– Onset of action is rapid (1‐2 min.)
– Duration 30‐60 min.
– Recurrence of respiratory depression due to short 
half life
half life
– Efficacy depends on pharmacokinetics and 
pharmacodynamics of individual opioid analgesic

Consider:
Nonsteroidal anti‐inflammatory drugs
Several meta‐analyses support conclusion that nonselective 
NSAIDs added to opioid regimens for post op pain resulted in 
reduced  incidence of opioid‐induced sedations
Screening preoperatively for pts at increased risk
Monitoring postoperatively in higher levels of care or 
more frequent vital signs or use of end‐tidal CO2 
monitoring
Be aware of renarcotization after naloxone and 
recurrence of respiratory depression
In patients on supplemental oxygen, consider which 
should have lower oxygen saturation targets
Jarzyna et al.Pain Management Nursing.2011;12(3):118-45

Polling Question…
M.S. risk factor(s) for postoperative opioid 
induced respiratory depression include 

Female sex

Obesity

Previous surgery

25
 Conclusion
• Neuromuscular blockade is important  to achieve  the best surgical 
conditions and added patient safety during delicate or critical  
surgeries. Residual paralysis is a patient safety concern.  Studies 
show frequency of residual block ranges from 2‐64%.

• Depending upon the risk, prophylaxis  should be initiated with 
monotherapy or combination therapy using interventions that
monotherapy or combination therapy using interventions that 
reduce baseline risk, nonpharmacologic approaches, and 
antiemetics.  Antiemetic combinations are recommended for 
patients at moderate to high risk for PONV. 

• Opioid analgesia is often required for pain control in the post 
operative setting. This is associated with a small but significant risk 
for respiratory depression.  Consider screening patients, monitoring 
at increased levels, addition of non‐opioid to opioid regimen.

26
 Residual Paralysis in PACU after a Single Intubating 
Dose of Nondepolarizing Muscle Relaxant of 
Intermediate Duration
Residual paralysis rate (%) between administration of muscle relaxant and arrival 
p y ( ) f
to PACU

Debaene. Anesthesiology.2003.;98:1042.

27
 Risk Factors For PONV In Adults
*
Evidence Risk Factors
Positive overall Female sex
History of PONV or Motion Sickness
Non‐smoking
Younger age
General vs. regional anesthesia (A1)
Use of volatile anesthetics and nitrous oxide (A1)
Postoperative opioids (A1)
Duration of anesthesia
Conflicting  ASA physical status
Type of surgery (cholecystectomy, laparoscopic, gynecological)
Menstrual cycle
Level of anesthetist’s experience
Muscle relaxant antagonists (A2)
Disproven or of limited  BMI
clinical relevance
clinical relevance Anxiety
Anxiety 
Nasogastric tube (A1)
Supplemental oxygen (A1)
Perioperative fasting (A2)
Migraine

Gan TJ et al. Anesth Analg. In manuscript preparation.

28
Algorithm for Management of PONV

Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the
management of postoperative nausea and vomiting. A&A. 2007;105:1615-28.

29
 KEY
Aprepitant=A
(HA, Elevated liver enzymes)
Ondansetron=O
(HA, Lightheadedness, Elevated liver enzymes,
A,D,O,G,S,Dr,P,Pa,Pc,Dm,Dp
Constipation, QT prolongation)
Dm,S Dp
Dolasetron=D
(HA, Lightheadedness, Elevated liver enzymes,
QT prolongation, Diarrhea)
Droperidol=Dr
S Dm Dp
S,Dm,Dp
(Sedation, dizziness, anxiety, hypotension, EPS,
QT prolongation, and Torsade de pointes)
Granisetron=G
(HA, Lightheadedness, Elevated liver enzymes, D, O, Dr, G,
Constipation) M,Pa,Pc, P
Dexamethasone=Dx
P
(Vaginal itching or anal irritation with IV bolus,
*Hyperglycemia (gluconeogenesis in liver))
Metoclopramide=M A ,O,
O D,
D
(Sedation, Hypotension, EPS)
Promethazine=P
G,S,Dx*
(Sedation, Hypotension, EPS, Possible severe
tissue irritation) S S
Scopolamine Patch=S
(Sedation, Dry mouth, Visual disturbances; CNS
effects in elderly patients, Renal or hepatic Dx
impairment) O, G, D,Pa,Dm,Dp
Palonosetron=Pa
(HA, Constipation, QT prolongation, Bradycardia)
Prochlorperazine=Pc
(Sedation, Hypotension, EPS)
Dimenhydrinate=Dm
(Sedation, dry mouth, blurred Antiemetic Man
vision, dizziness, urinary retention)
Diphenhydramine=Dp Common side effects with traditional antiemetic
(Sedation, dry mouth, blurred
vision, dizziness, urinary retention) medications

30
 Managing Postoperative Complications
Related to Anesthesia
S E L E C T E D R E F E R E N C E S A N D R E S O U R C E S
Apfel CC, Korttila K, Abdalla M et al. A factorial trial of six interventions for the
prevention of postoperative nausea and vomiting. N Engl J Med. 2004; 350:2441-51.
Apfel CC, Philip BK, Cakmakkaya OS et al. Who is at risk for postdischarge nausea and
vomiting after ambulatory surgery? Anesthesiology. 2012; 117:475-86.
Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement
projects: national initiatives to improve outcomes for patients having surgery. Clin Infect
Dis. 2006; 43:322-30.
Caldwell JE. What’s new in…muscle relaxants. American Society of Anesthesiologists
newsletter. September 2003. Available at:
http://asatest.asahq.org/Newsletters/2003/09_03/whatsNew09_03.html (accessed 2012
Nov 7).
Carroll NV, Miederhoff P, Cox FM et al. Postoperative nausea and vomiting after
discharge from outpatient surgery centers. Anesth Analg. 1995; 80:903-9.
Claudius C; Karacan H; Viby-Mogensen J. Prolonged residual paralysis after a single
intubating dose of rocuronium. Br J Anaesth 2007; 99: 514-17.
Debaene B, Plaud B, Dilly MP et al. Residual paralysis in the PACU after a single
intubating dose of nondepolarizing muscle relaxant with an intermediate duration of
action. Anesthesiology. 2003; 98:1042-8.
Eriksson LI. Evidence-based practice and neuromuscular monitoring: it's time for routine
quantitative assessment. Anesthesiology. 2003; 98:1037-9.
Gan TJ, Meyer TA, Apfel CC et al. Society for Ambulatory Anesthesia guidelines for the
management of postoperative nausea and vomiting. Anesth Analg. 2007; 105:1615-28.
Grayling M, Sweeney BP. Recovery from neuromuscular blockade: a survey of practice.
Anaesthesia. 2007; 62:806-9.
Hayes AH, Mirakhur RK, Breslin DS et al. Postoperative residual block after
intermediate-acting neuromuscular blocking drugs. Anaesthesia. 2001; 56:312-8.
Jarzyna D, Jungquist CR, Pasero C et al. American Society for Pain Management
Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression.
Pain Manag Nurs. 2011; 12:118-45.
Kassin MT, Owen RM, Perez SD et al. Risk factors for 30-day hospital readmission
among general surgery patients. J Am Coll Surg. 2012; 215:322-30.
Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-four fade ratio to clinical
signs and symptoms of residual paralysis in awake volunteers. Anesthesiology. 1997;
86:765-71.
Marcario A, Weinger M, Carney S et al. Which clinical anesthesia outcomes are
important to avoid? The perspective of patients. Anesth Analg. 1999; 89:652-8.

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 Managing Postoperative Complications
Related to Anesthesia
Maybauer D M, Geldner G, Blobner M, et al. Incidence and duration of residual
paralysis at the end of surgery after multiple administrations of cisatracurium and
rocuronium. Anesthesia 2007: 62:12-17
Murphy Glenn S, Szokol Joseph W et al. Residual paralysis at the time of tracheal
extubation. Anesth Analg. 2005; 100:1840-5
Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I:
definitions, incidence, and adverse physiologic effects of residual neuromuscular block.
Anesth Analg. 2010; 111:120-8.
Murphy GS, Szokol JW, Marymont JH et al. Residual paralysis at the time of tracheal
extubation. Anesth Analg. 2005; 100:1840-5.
Murphy GS. Residual neuromuscular blockade: incidence, assessment, and relevance in
the postoperative period. Minerva Anestesiol. 2006; 72:97-109.
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Churchill Livingstone Elsevier; 2010:859-912.
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surgery: a modelling strategy based on available data. Lancet. 2008; 372:139-44.

32
 Managing Postoperative Complications
Related to Anesthesia
S E L F – A S S E S S M E N T Q U E S T I O N S
1. Neuromuscular blocking agents are used for which of the following?
a. Muscle relaxation during endotracheal intubation.
b. Muscle relaxation during the surgical procedure to prevent movement.
c. Both a and b are correct.
d. Neither a or b is correct.

2. Which of the following reversal agents is most frequently used in surgery?

a. Edrophonium.
b. Neostigmine.
c. Pyridostigmine.
d. Vecuronium.

3. Which of the following anesthetic drugs is most likely to increase the risk for
postoperative nausea and vomiting?
a. Muscle relaxant antagonists.
b. Volatile anesthetics.
c. Propofol.
d. Regional dexamethasone.

4. Which of the following is an antiemetic agent with evidence of efficacy for decreasing
the risk of postoperative nausea and vomiting in surgical patients?
a. Metoclopramide.
b. Ondansetron.
c. Cannabinoids.
d. Bromocriptine.

5. Which of the following is a risk factor for opioid-induced respiratory depression?

a. Nonsmoking.
b. Insomnia.
c. Obesity.
d. Female sex.

6. Which of the following choices applies to patients at risk for postoperative opioid-
induced respiratory depression?
a. Monitored in higher levels of care.
b. Not be given opioids.
c. Not be given local anesthetics.
d. Not be given general anesthesia.

Answers
1. c
2. b
3. b
4. b
5. c
6. a

33
Managing Postoperative Complications
Related to Anesthesia

34