What is the appropriate management for an 81-year-old female with a diagnosis of strangulated ventral hernia and small bowel obstruction (SBO), presenting with nausea, having last received Zofran (ondansetron) at 0000?

From the Guidelines

I strongly recommend against administering another dose of ondansetron (Zofran) at this time and instead suggest metoclopramide 10 mg IV as an alternative for this 81-year-old female patient with strangulated ventral hernia and small bowel obstruction who is experiencing nausea. The patient's condition of strangulated ventral hernia and small bowel obstruction (SBO) requires careful management of nausea to prevent vomiting, which could exacerbate her condition 1. Given her diagnosis, it is crucial to prioritize interventions that do not delay definitive surgical management. The standard approach for managing SBO, as outlined in the Bologna guidelines 1, emphasizes the importance of non-operative treatment for most patients, but given this patient's strangulation, operative treatment is likely necessary. Key considerations in her management include:

• Maintaining nil per os (NPO) status to rest the bowel
• Ensuring adequate IV hydration and electrolyte supplementation
• Monitoring for signs of clinical deterioration
• Considering the use of antiemetics to control nausea and prevent vomiting Given the potential for metoclopramide to enhance gastric emptying, it may be a preferable option in this scenario, although it should be used cautiously in patients with bowel obstruction 1. It is essential to weigh the benefits and risks of each medication and to consider the patient's overall clinical status when selecting an antiemetic regimen.

From the Research

Nausea Management for 81 YO F with Strangulated Ventral Hernia and SBO

• The patient is complaining of nausea and was last given Zofran at 0000.
• Studies have compared the efficacy of ondansetron and metoclopramide in reducing nausea and vomiting in various clinical settings 2, 3, 4, 5.
• A study published in 2017 found that both ondansetron and metoclopramide were effective in preventing postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy, with ondansetron being more effective in preventing nausea 2.
• Another study published in 2014 found that ondansetron, metoclopramide, and placebo had similar reductions in nausea severity in adult emergency department patients with undifferentiated nausea and vomiting 3.
• A study published in 2001 found that prophylactic administration of metoclopramide or ondansetron significantly reduced the incidence of postoperative vomiting for laparoscopic cholecystectomy, but neither drug was found to be significantly more effective than the other 4.
• A recent study published in 2023 found that the combination of metoclopramide and ondansetron was effective in reducing the incidence of PONV after sleeve gastrectomy, and was recommended as the antiemetic regimen for reduction of PONV after sleeve gastrectomy 5.
• Metoclopramide has also been studied in the context of pseudo-obstruction of the bowel, but was found to be ineffective in a therapeutic trial published in 1977 6.

Antiemetic Options

• Ondansetron and metoclopramide are both viable options for managing nausea in this patient.
• The choice of antiemetic may depend on various factors, including the patient's medical history, current medications, and the severity of their nausea.
• Combination therapy with metoclopramide and ondansetron may be considered, as it has been shown to be effective in reducing PONV in certain clinical settings 5.