2023 FSA Podium and Poster Abstracts
P056: IMPLEMENTATION OF PROTOCOL IN PACU WITH AMISULPRIDE AS RESCUE TREATMENT FOR REFRACTORY PONV
Giselle Helo, MD, FASA1; Veronica De Leon, PharmaD, BCPS2; Targol Tarahomi, BS3; Benjamin T Houseman, MD, PhD, FASA1; Elham Shams, MHS, MS3; Marisol Perales, MD1; Clint Christensen, DO1; Gary Gomez, MD, MBA, FASA1; 1Envision Physician Services; 2Memorial Healthcare System; 3Nova Southeastern University Dr Kieran C Patel College of Osteopathic Medicine
Introduction/Background: Postoperative Nausea and Vomiting (PONV) impacts nearly 30 percent of patients after surgery, resulting in decreased patient satisfaction and increased cost of care due to increased length of stay in the Post-Anesthesia Care Unit (PACU). This incidence of PONV increases in patients with female gender, non-smoking status, and a previous history of PONV. Recently, amisulpride was approved by the FDA for both PONV prophylaxis and treatment. This medication is a selective D2 and D3 receptor antagonist with low affinity for 5-HT2B and 5-HT7A serotonin receptor subtypes as well as minimal interaction with potassium channels which reduces its impact on QT prolongation. Compared to other dopamine antagonists, amisulpride has low blood-brain barrier permeability, resulting in less extrapyramidal symptoms and a more favorable side effect profile.
Methods: Our institution utilizes a standardized Enhanced Recovery After Surgery (ERAS) protocol, with PONV risk stratification based on the APFEL scoring tool. Patients receive standardized PONV prophylaxis regimens preoperatively based on APFEL score. Patients greater than 65 years of age receive modified PONV prophylaxis regimens that consider American Geriatric Society Beers criteria.
We implemented a system-wide protocol in our Electronic Medical Record (EMR) to include amisulpride as an option for rescue therapy for refractory PONV in the postoperative care unit (PACU). Amisulpride was available as a one-time rescue dose after two other standard PONV prophylaxis and treatment therapies had failed.
Results: Data from Anesthesia Pulse in EPIC was extracted to analyze PACU antiemetic rate and average antiemetic doses in 2022 and 2023. The total anesthesia records in 2022 were 1,898 with an average recovery time of 2h 39m. As of February 10, 2023, there were a total of 227 anesthesia cases at our institution with an average recovery time of 2h 34min. Before amisulpride was available in our system, the use of antiemetics in PACU was 7%. When amisulpride became available in 2023, the use of antiemetics in PACU was 6%. The average number of antiemetic doses given in PACU was 1 and did not change from 2022 to 2023. In 2023, 14 patients in the system received amisulpride for rescue treatment. All patients who received amisulpride demonstrated full recovery, and none were readmitted for intractable refractory PONV.
Discussion/Conclusion: PONV is a complex problem that negatively impacts both patient satisfaction and healthcare costs. Current regimens for prophylaxis and treatment are insufficient for many high-risk patients. The introduction of amisulpride, a novel therapy agent with a different mechanism of action, represents a significant addition to prophylaxis and treatment options. In our observational study, we found that a protocol for the use of amisulpride in PACU for rescue PONV is effective. Further data collection is warranted to quantify the impact of amisulpride in our practice, with specific emphasis on patient satisfaction, PACU length of stay, and cost-benefit analysis.
Reference
Gan, Tong J et al .Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting.Anesthesia & Analgesia 131(2):p 411-448, August 2020