Pharmacists Play Important Role in Postoperative Nausea, Vomiting

In an interview with Pharmacy Times® at the American Society of Health-System Pharmacists Midyear Meetings and Exhibition, Jawad Saleh, PharmD, BSPharm, BCCCP, BCPS, clinical manager of Pharmacy Services at the Hospital for Special Surgery, discusses how pharmacists can treat postoperative nausea and vomiting.

Q: Can you describe the challenges that postoperative nausea and vomiting creates for patients and their care providers?

Jawad Saleh: Postoperative nausea vomiting has multiple levels of challenges. You have your patient experience challenges, your patient satisfaction challenges, patients that are retching or vomiting or there's emesis, or even nauseous; they are not happy. There's even a survey that was out there that went through patient experience, would you rather have severe pain or would you rather have nausea and vomiting, and most of them chose I'd rather have pain than nausea vomiting.

It really, really affects patient experience that way, and when you discuss patient experience as a whole, there is an impact on financial when you involve that in HCAP scores and other surveys. You also have the financial impact, whether it's length of stay, whether it's incremental cost of medications being used. Again, the value-based purchasing approach, when you look at the bigger picture, and the patient's experience, so there's many levels to the challenges that we're dealing with. Obviously, one of the biggest challenges is, are people really following guidelines? Are there order sets that we need in place? And is this something that's really being practiced? The best practices on an institutional level? These are really important and specifically again, and is rescue treatment, and understanding what you need to do and the limited medications we do have and how to maneuver is really important as pharmacists.

Q: What is the pharmacist’s role in treating postoperative nausea and vomiting?

Jawad Saleh: I'm a big advocate for pharmacists taking charge. We seem to have full control, or somewhat of a leadership role, in antimicrobial stewardship. We seem to have a role in anticoagulation task forces, and we are co-chairs or secretaries of pharmacy and therapeutics committees. I really feel that opioid stewardship is becoming a really big push and a big move. I think, postoperative nausea vomiting, a big portion of it, of course does have something to do with opioid use as well as that's one of the adverse effects and complications of opioids. Pharmacists really need to take hold of the reins when it comes to postoperative care. We should be involved in policymaking, utilizing evidence-based medicine to create policies, and those policies coincide with the EHR/EMR, whatever you're using at your organization, we use EPIC, and creating pathways in order sets and making sure that MUEs and DUEs are being done to make to monitor that the medications being used in PONV are the correct and most efficient medications to use.

Q: What are the guidelines for treatment of postoperative nausea and vomiting that pharmacists should be aware of?

Jawad Saleh: TJ Gan and team just published the fifth consensus guidelines for PONV. It's out there. It really with rescue, I think, that's one of the more challenging parts of PONV, in general. Prophylaxis prevention is difficult to manage at times, but if done correctly and monitored based on risk factors, it's extremely beneficial. We do have a guide to how many agents to use per risk factor, but treatment gets very tricky. That is due to not utilizing the same agent with the same mechanism of action within 6 hours of giving it and most of us give ondansetron, methadone, and these agents in the operating room. When they come out into the pack unit recovery room or they're ready to go home and an ambulatory center, we utilize the same agents again within that 6-hour timeframe. In reality, if you look at some of the data that exists, giving it within 6 hours is equivalent to placebo. It seems like this is the common culture and mechanism of order entry or prescribing for these agents.