What are the methods for preventing postoperative nausea and vomiting (PONV) in patients undergoing ambulatory surgery?

From the Guidelines

For ambulatory surgery PONV prevention, a multimodal approach using at least 2 antiemetic drugs such as dexamethasone and ondansetron is strongly recommended. This approach is based on the latest guidelines from the ERAS society recommendations 2022, which emphasize the importance of a multimodal approach to prevent PONV 1. The use of 5-HT3 antagonists, such as ondansetron, as the primary treatment is recommended due to their safe side effect profile. Additionally, low-dose dexamethasone is a good additive preventative agent and facilitates hepatic regeneration 1.

When assessing patients for PONV risk, factors such as previous PONV, female gender, younger age, non-smoker, and use of volatile anesthetic agents and opioids should be evaluated 1. For patients at moderate to high risk of PONV, the use of a combination of antiemetic drugs, such as dexamethasone and ondansetron, is recommended to decrease PONV and improve efficacy 1.

Key considerations for PONV prevention in ambulatory surgery include:

• Using a multimodal approach with at least 2 antiemetic drugs
• Assessing patients for PONV risk factors
• Using 5-HT3 antagonists, such as ondansetron, as the primary treatment
• Adding low-dose dexamethasone as a preventative agent
• Considering alternative antiemetic agents, such as antihistamines, butyrophenones, and phenothiazines, as second-line therapy 1.

By following this approach, the risk of PONV can be significantly reduced, improving recovery time, patient satisfaction, and reducing unplanned admissions after ambulatory surgery 1.

From the FDA Drug Label

In a placebo-controlled trial conducted in 468 males undergoing outpatient procedures, a single 4-mg intravenous ondansetron dose prevented postoperative vomiting over a 24-hour period in 79% of males receiving drug compared with 63% of males receiving placebo (P <0. 001).

PONV Prevention for Ambulatory Surgery:

• Ondansetron (IV) is effective in preventing postoperative nausea and vomiting (PONV) in ambulatory surgery patients, with a single 4-mg dose preventing vomiting in 79% of patients compared to 63% with placebo 2.
• The use of ondansetron (IV) is recommended for patients undergoing ambulatory surgery who are at risk of PONV.
• No additional benefit was observed with an 8-mg dose compared to a 4-mg dose of ondansetron (IV) 2.

From the Research

Prevention of Postoperative Nausea and Vomiting (PONV) in Ambulatory Surgery

• PONV is a common complication in surgical patients, which can delay post-anesthetic care unit discharge, prolong hospital stay, and increase the cost of hospitalization 3.
• The prophylactic administration of antihistamines, antidopaminergics, anticholinergics, phenothiazines, serotonin antagonist, steroids, and acupuncture has been shown to be effective in preventing PONV 3.
• A study found that the prophylactic intravenous administration of 10 mg dexamethasone immediately before the induction of anesthesia is effective in preventing PONV in the general surgical adult patient population 3.
• The management of PONV involves a framework of risk assessment, multimodal risk reduction, and prophylactic measures, as well as prompt rescue treatment 4.
• A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV 5.

Risk Assessment and Prophylaxis

• Patient, anesthesia, and surgery-related risk factors have been identified, and universal PONV prophylaxis is not cost-effective 6.
• Identification of patients at high-risk of PONV allows targeting prophylaxis to those who will benefit most from it, and no prophylaxis is needed for patients at low risk for PONV 6.
• For patients at moderate risk for PONV, prophylaxis using a single antiemetic or a combination of two agents should be considered, and double and triple antiemetic combinations should be considered for patients at high risk for PONV 6.

Management of PONV in Ambulatory Surgery

• PONV continues to be one of the most common complaints following surgery, occurring in more than 30% of surgeries, or as high as 70% to 80% in certain high-risk populations without prophylaxis 7.
• The 5-hydroxytryptamine type 3 (5-HT(3)) receptor antagonists continue to be the mainstay of antiemetic therapy, but newer approaches, such as neurokinin-1 antagonists, a longer-acting serotonin receptor antagonist, multimodal management, and novel techniques for managing high-risk patients are gaining prominence 7.
• The related problem of postdischarge nausea and vomiting (PDNV) has received increasing attention from health care providers, and it is particularly important to prevent and treat PONV and PDNV swiftly and effectively in the context of ambulatory surgeries 7.