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Postoperative nausea and vomiting — Clinical Guidelines

Overview

Postoperative nausea and vomiting (PONV) is a common complication following surgery and anesthesia, affecting 25%-30% of patients postoperatively and impacting recovery and discharge 5.

Diagnosis

Clinical diagnosis based on patient reporting of nausea and vomiting symptoms post-surgery 4.

No specific diagnostic tests; assessment often includes patient history and postoperative observation 4.

Management

First-line treatments:

- 5HT3 receptor antagonists: Ondansetron (4 mg IV) 6 19. - Dexamethasone: 4 mg IV for prophylaxis 3 12.

Adjunctive treatments:

- Droperidol: 0.625 mg or 0.5 mg IV 6 14 19. - Metoclopramide: 5 mg IV 6 14. - Tropisetron: Comparable efficacy to ondansetron 6.

Opioid-free anesthesia: May reduce PONV incidence compared to opioid-based anesthesia 1.

Special Populations

Pregnancy: Intrathecal morphine use requires careful antiemetic prophylaxis; dexamethasone and low-dose droperidol combination effective 12.

Pediatrics: Not specifically addressed in abstracts provided.

Elderly: Higher risk for PONV; tailored prophylaxis based on risk stratification recommended 7.

Comorbidities: Patients with higher risk factors (e.g., female gender, non-smokers, history of PONV) require more aggressive prophylaxis 7 5.

Key Recommendations

Implement risk stratification tools: Use simplified Apfel's score for preoperative assessment to guide prophylaxis 7 (Evidence: Moderate).

Utilize opioid-free anesthesia: Consider opioid-free anesthesia regimens to potentially reduce PONV incidence 1 (Evidence: Moderate).

Employ combination antiemetic therapy judiciously: Dexamethasone combined with low-dose droperidol may effectively prevent PONV post-cesarean section 12 (Evidence: Moderate).

Continuous performance feedback: Ongoing provision of individual clinician performance data improves adherence to PONV prophylaxis guidelines 8 (Evidence: Moderate).

Cost-awareness in medication selection: Consider acquisition costs while selecting PONV medications, especially in resource-limited settings 2 (Evidence: Weak).

References

1 Zhang Y, Ma D, Lang B, Zang C, Sun Z, Ren S et al.. Effect of opioid-free anesthesia on the incidence of postoperative nausea and vomiting: A meta-analysis of randomized controlled studies. Medicine 2023. link 2 Mehallow CSM, Noble CPJ. Assessment of Cost-awareness and Likelihood to Consider Costs for Postoperative Nausea and Vomiting Medications in a Military Anesthesia Department. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses 2022. link 3 Corcoran TB, Edwards T. A survey of antiemetic dexamethasone administration-frequency of use and perceptions of benefits and risks. Anaesthesia and intensive care 2015. link 4 Motamed C, Bourgain JL. Postoperative nausea and vomiting in the post-anesthetic care unit, a 5-year survey of a quality assurance program in surgical cancer patients. Bulletin du cancer 2015. link 5 Cruthirds D, Sims PJ, Louis PJ. Review and recommendations for the prevention, management, and treatment of postoperative and postdischarge nausea and vomiting. Oral surgery, oral medicine, oral pathology and oral radiology 2013. link 6 Ekinci O, Malat I, Işıtmangil G, Aydın N. A randomized comparison of droperidol, metoclopramide, tropisetron, and ondansetron for the prevention of postoperative nausea and vomiting. Gynecologic and obstetric investigation 2011. link 7 Sigaut S, Merckx P, Peuch C, Necib S, Pingeon F, Mantz J. Does an educational strategy based on systematic preoperative assessment of simplified Apfel's score decrease postoperative nausea and vomiting?. Annales francaises d'anesthesie et de reanimation 2010. link 8 Frenzel JC, Kee SS, Ensor JE, Riedel BJ, Ruiz JR. Ongoing provision of individual clinician performance data improves practice behavior. Anesthesia and analgesia 2010. link 9 Habib AS, Gan TJ. The use of droperidol before and after the Food and Drug Administration black box warning: a survey of the members of the Society of Ambulatory Anesthesia. Journal of clinical anesthesia 2008. link 10 Sarin P. Encouraging change in anesthesiology practice through electronic feedback to physicians: results from prototype system. AMIA ... Annual Symposium proceedings. AMIA Symposium 2007. link 11 Raeder J, Dahl V, Bjoernestad E, Edlund G, Modin S, Naucler E et al.. Does esomeprazole prevent post-operative nausea and vomiting?. Acta anaesthesiologica Scandinavica 2007. link 12 Wu JI, Lo Y, Chia YY, Liu K, Fong WP, Yang LC et al.. Prevention of postoperative nausea and vomiting after intrathecal morphine for Cesarean section: a randomized comparison of dexamethasone, droperidol, and a combination. International journal of obstetric anesthesia 2007. link 13 Marcus JR, Few JW, Chao JD, Fine NA, Mustoe TA. The prevention of emesis in plastic surgery: a randomized, prospective study. Plastic and reconstructive surgery 2002. link 14 Uerpairojkit K, Pavaves B, Nalawachai J. A placebo-controlled, randomized trial of droperidol versus metoclopramide for outpatients undergoing gynecological laparoscopy under conscious sedation. Journal of the Medical Association of Thailand = Chotmaihet thangphaet 2002. link 15 Macario A, Chung A, Weinger MB. Variation in practice patterns of anesthesiologists in California for prophylaxis of postoperative nausea and vomiting. Journal of clinical anesthesia 2001. link00283-5) 16 Soppitt AJ, Glass PS, Howell S, Weatherwax K, Gan TJ. The use of propofol for its antiemetic effect: a survey of clinical practice in the United States. Journal of clinical anesthesia 2000. link00151-3) 17 Wilder-Smith OH, Martin NC, Morabia A. Postoperative nausea and vomiting: a comparative survey of the attitudes, perceptions, and practice of Swiss anesthesiologists and surgeons. Anesthesia and analgesia 1997. link 18 Cohen MM, Rose DK, Yee DA. Changing anesthesiologists' practice patterns. Can it be done?. Anesthesiology 1996. link 19 Tang J, Watcha MF, White PF. A comparison of costs and efficacy of ondansetron and droperidol as prophylactic antiemetic therapy for elective outpatient gynecologic procedures. Anesthesia and analgesia 1996. link

Postoperative nausea and vomiting