How can postoperative nausea and vomiting (PONV) be predicted and prevented in patients undergoing laparoscopic surgeries?

From the Guidelines

Postoperative nausea and vomiting (PONV) in laparoscopic surgery patients can be predicted using risk assessment tools, such as the Apfel score, and prevented through a multimodal approach, including pharmacological and non-pharmacological interventions, as recommended by the Enhanced Recovery After Surgery (ERAS) society 1. The Apfel score identifies four major risk factors: female gender, non-smoking status, history of PONV or motion sickness, and expected postoperative opioid use. Each factor increases PONV risk by approximately 20%, with patients having all four factors facing an 80% risk.

• Prevention should be tailored to risk level, with high-risk patients receiving combination prophylaxis.
• Effective pharmacological options include 5-HT3 antagonists (ondansetron 4mg IV at end of surgery), dexamethasone (4-8mg IV at induction), and NK1 receptor antagonists (aprepitant 40mg oral) 1.
• Non-pharmacological approaches include adequate hydration (20-30 ml/kg crystalloids), minimizing opioid use through multimodal analgesia (acetaminophen, NSAIDs, regional anesthesia), using propofol for induction and maintenance, avoiding nitrous oxide and volatile anesthetics when possible, and maintaining normothermia.
• Total intravenous anesthesia (TIVA) with propofol reduces PONV risk compared to volatile anesthetics, as supported by recent guidelines 1. Implementing these strategies based on individual risk assessment significantly reduces PONV incidence and improves patient comfort after laparoscopic procedures, ultimately reducing morbidity, mortality, and improving quality of life.
• The use of prophylactic analgesia with paracetamol has also been shown to be beneficial in reducing PONV incidence 1.
• A multimodal approach to PONV prophylaxis should be considered in all patients and incorporated into ERAS protocols, with patients having 1-2 risk factors receiving a two-drug combination prophylaxis using first-line antiemetics, and patients with 2 or more risk factors receiving 2-3 antiemetics 1.

From the FDA Drug Label

The populations in Table 10 consisted mainly of females undergoing laparoscopic procedures 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).

Prediction and Incidence of PONV in Laparoscopic Surgeries:

• The incidence of PONV in laparoscopic surgeries can be significant, with a notable portion of patients experiencing nausea and vomiting postoperatively.
• Risk Factors: Although not explicitly stated in the provided drug labels, general risk factors for PONV include female gender, nonsmoking status, history of PONV or motion sickness, and the type of surgery (with laparoscopic procedures being among those that carry a risk) 2.
• Prevention: Ondansetron, given as a single 4-mg intravenous dose, has been shown to be effective in preventing postoperative nausea and vomiting in patients undergoing laparoscopic procedures, with a significant reduction in the incidence of emetic episodes compared to placebo 2 2.
• Key Considerations:
  • The effectiveness of ondansetron in preventing PONV highlights the importance of prophylactic antiemetic therapy in patients at risk.
  • The choice of antiemetic should be based on the patient's individual risk factors, the type of surgery, and the anesthetic technique used.
  • Multimodal approaches to PONV prevention, including the use of different classes of antiemetics and nonpharmacological strategies, may offer enhanced protection against PONV.

From the Research

Prediction of PONV in Laparoscopic Surgeries

• The prediction of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic surgeries can be achieved through various risk scores, such as the Apfel-score 3 and a simplified risk score 4.
• These risk scores take into account factors such as female gender, history of motion sickness or PONV, nonsmoking, and the use of postoperative opioids 4.
• The Apfel-score has been validated in patients with high risk for PONV and has been shown to be a useful tool for stratification of patients with high risk for PONV 3.
• A study comparing three different risk scores found that all three scores had moderate accuracy in predicting PONV, but the score published by Koivuranta was recommended for clinical practice due to its simplicity 5.

Incidence of PONV in Laparoscopic Surgeries

• The incidence of PONV in patients undergoing laparoscopic surgeries can be reduced through the use of multimodal anti-emetic prophylaxis, such as total intravenous anesthesia with propofol, high fractional inspired oxygen, omission of nitrous oxide, dexamethasone, haloperidol, and tropisetron 6.
• Intraoperative laser acupuncture combined with antiemetic drugs has also been shown to be effective in reducing the incidence of PONV in patients undergoing laparoscopic cholecystectomy 7.
• The use of a simplified risk score can help identify patients at high risk for PONV, allowing for targeted prophylactic antiemetic strategies 4.

Prevention of PONV in Laparoscopic Surgeries

• A multimodal anti-emetic approach can considerably reduce the incidence of PONV in high-risk patients and is associated with high patient satisfaction 6.
• Intraoperative laser acupuncture stimulation of Pericardium 6 (PC6) and Large Intestine 4 (LI4) acupoints combined with antiemetic drug prophylaxis can decrease nausea and rescue antiemetic drug need in the late postoperative period 7.
• The use of a simplified risk score can help guide the selection of patients who would benefit from prophylactic antiemetic strategies, reducing the incidence of PONV and improving patient outcomes 4.