PONV Management

Based on the Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting (PONV)

Risk Assessment

Risk Factors

• Patient-specific factors (evidence B1):

  • Female gender

  • History of PONV or motion sickness

  • Non-smoking status

  • Young age

• Surgery-specific factors (evidence B1):

  • Laparoscopic procedures

  • Bariatric surgery

  • Gynecological surgery

  • Cholecystectomy

• Anesthetic risk factors:

  • Volatile anesthetics (dose-dependent, especially first 2-6 hours) (evidence A1)

  • Nitrous oxide (duration-dependent, significant if >1 hour) (evidence A1)

  • Postoperative opioids (dose-dependent) (evidence A1)

Risk Scoring Systems for Adults

• Apfel Score: 0, 1, 2, 3, or 4 risk factors correspond to PONV risks of approximately 10%, 20%, 40%, 60%, and 80%, respectively

  • Female gender

  • History of PONV/motion sickness

  • Non-smoking status

  • Postoperative opioid use

• Risk Categories:

  • Low risk: 0-1 risk factors

  • Medium risk: 2 risk factors

  • High risk: 3+ risk factors

• PDNV Risk Score (Post-Discharge Nausea and Vomiting):

  • Female gender

  • Age <50 years

  • History of PONV

  • Opioid use in PACU

  • Nausea in PACU

Paediatric Risk Factors

• Age >3 years

• Surgery duration >30 minutes

• Strabismus surgery

• History of POV/PONV in patient or first-degree relative

• Postpubertal females

Pediatric Risk Scoring (POVOC Score)

• 0, 1, 2, 3, or 4 risk factors correspond to POV risks of approximately 10%, 10%, 30%, 50%, or 70%, respectively

Prevention Strategies

General strategies

• Use regional anesthesia instead of general anesthesia when possible

• Propofol for induction and maintenance (TIVA)

• Avoid nitrous oxide in surgeries lasting >1 hour

• Avoid volatile anesthetics

• Minimise intraoperative and postoperative opioids

• Ensure adequate hydration (10-30 mL/kg crystalloids)

• Consider using sugammadex instead of neostigmine for neuromuscular blockade reversal

Multimodal Analgesia to Reduce PONV

• IV acetaminophen (given before onset of pain) (evidence A1)

• NSAIDs (evidence A1)

• COX-2 inhibitors (evidence A1)

• Dexmedetomidine (evidence A1)

• Esmolol (evidence A3)

Prophylactic Antiemetics for Adults

• Major change in 2020 guidelines: Recommend multimodal prophylaxis (at least 2 antiemetics) for patients with 1 or more risk factors

• 5-HT3 Receptor Antagonists:

  • Ondansetron: 4 mg IV or 8 mg PO/ODT (evidence A1)

  • Granisetron: 0.35-3 mg IV (evidence A1)

  • Palonosetron: 0.075 mg IV (evidence A1)

  • Ramosetron: 0.3 mg IV (evidence A1)

• NK1 Receptor Antagonists:

  • Aprepitant: 40 mg PO (evidence A1)

  • Fosaprepitant: 150 mg IV (evidence A1)

• Corticosteroids:

  • Dexamethasone: 4-8 mg IV at induction (evidence A1)

  • Methylprednisolone: 40 mg IV (evidence A2)

• Antidopaminergics:

  • Amisulpride: 5 mg IV (evidence A2)

  • Droperidol: 0.625 mg IV (evidence A1)

  • Haloperidol: 0.5-2 mg IM/IV (evidence A1)

  • Metoclopramide: 10 mg (evidence A1)

• Other Agents:

  • Scopolamine: transdermal patch (evidence A1)

  • Dimenhydrinate: 1 mg/kg IV (evidence A1)

  • Gabapentin: 600-800 mg PO (evidence A1)

  • Midazolam: at induction (evidence A1)

Prophylactic Antiemetics for Children

• Recommended agents:

  • Ondansetron: 50-100 μg/kg up to 4 mg (evidence A1)

  • Dexamethasone: 150 μg/kg up to 5 mg (evidence A1)

  • Combination of ondansetron + dexamethasone (evidence A1)

Treatment Approaches

Treatment of Established PONV

• Key principle: Use antiemetic from a different pharmacological class than those used for prophylaxis

• Do not repeat same class of antiemetic within 6 hours (evidence A2)

• First-line options:

  • 5-HT3 antagonists: ondansetron 4 mg IV, ramosetron 0.3 mg IV

  • Amisulpride 5-10 mg IV

  • Promethazine 6.25 mg IV

  • Droperidol 0.625 mg IV

• For rescue after failed prophylaxis:

  • Consider NK1 receptor antagonists

  • Consider combination therapy with multiple antiemetics

Treatment of PDNV

• Multimodal antiemetics are more effective than monotherapy

• Consider extended-release formulations or longer-acting agents

Implementation strategies

Institutional Protocol Development

• Implement PONV management protocols

• Consider general multimodal prophylaxis for all at-risk patients

• Ensure timely treatment of established PONV

• Regular compliance and outcome measurements

Enhanced Recovery Pathways (ERPs)

• PONV management is a vital component of ERPs

• Multimodal prophylaxis recommended for all surgical patients with any risk factors

• Baseline risk reduction strategies should be incorporated into ERPs

Key messages

1. Risk assessment should be performed for all patients

2. Multimodal prophylaxis (≥2 agents) is now recommended for patients with ≥1 risk factor

3. Use antiemetics from different classes for combination therapy

4. For treatment of established PONV, use an agent from a different class than prophylaxis

5. Consider both pharmacological and non-pharmacological approaches

6. Implement institutional protocols with regular monitoring and evaluation