Is postoperative nausea and vomiting in children acceptable?

Postoperative Nausea and Vomiting in Children is Not Acceptable and Requires Aggressive Management

Postoperative nausea and vomiting (PONV) in children is not acceptable and should be aggressively prevented and treated as it causes significant morbidity, delays discharge, and is a leading cause of readmission to hospitals. 1, 2 PONV occurs twice as frequently in children as in adults, increasing until puberty and then decreasing to adult rates, making it an even more critical issue in pediatric surgical care.

Risk Factors for PONV in Children

• Age-related risk: Children 3-13 years have higher risk, with girls >13 years having particularly high rates 3
• Surgical procedures: Strabismus repair and adenotonsillectomy are the most emetogenic procedures 1, 2
• Patient history: Previous PONV or motion sickness significantly increases risk 3
• Anesthetic factors: Use of opioids, volatile anesthetics, and neuromuscular reversal agents increases risk 3

Prevention Strategy

Preoperative Assessment and Risk Reduction

1. Identify high-risk patients (3-13 years old, girls >13 years, history of motion sickness/previous PONV)
2. Consider multimodal prophylaxis for moderate-to-high risk patients

Anesthetic Technique Modifications

1. Consider regional anesthesia when possible instead of general anesthesia 1
2. If general anesthesia is required:
   • Use propofol for induction and maintenance (TIVA) 3
   • Avoid nitrous oxide when possible
   • Minimize use of opioids through multimodal analgesia
   • Avoid unnecessary neuromuscular blockade reversal agents 3

Prophylactic Antiemetic Therapy

For high-risk children, a multimodal approach using at least two antiemetic drugs from different classes should be implemented 4:

1. First-line combination: Ondansetron 0.1 mg/kg (max 4mg) IV + dexamethasone 0.1-0.15 mg/kg (max 8mg) IV 4, 5

   • Ondansetron should be administered immediately prior to or following anesthesia induction 5
   • Dexamethasone should be given at the beginning of surgery 4

2. For very high-risk patients (≥3 risk factors): Add a third agent such as droperidol or metoclopramide 4

Perioperative Management

• Ensure adequate hydration 6
• Minimize patient movement in the immediate postoperative period 7
• Provide a quiet environment 7
• Do not force oral intake before the child is ready 7

Treatment of Established PONV

When PONV occurs despite prophylaxis:

1. Administer rescue medication from a different class than those used for prophylaxis 4

   • If ondansetron was used for prophylaxis, consider promethazine or droperidol
   • If inadequate response, add metoclopramide 10mg IV (dose-adjusted for children) 4

2. For persistent symptoms:

   • Consider around-the-clock administration rather than as-needed dosing 4
   • Add scopolamine (transdermal) for older children with persistent symptoms 4

Special Considerations

Adenotonsillectomy Patients

Children undergoing adenotonsillectomy require special attention as they are at high risk for PONV and postoperative complications:

• Ensure proper hydration until oral intake is fully re-established 6
• Consider nasopharyngeal airway placement under direct vision by the ENT surgeon in children <5 years or with severe obstructive sleep apnea 6
• Treat PONV promptly as it can worsen postoperative pain and delay oral intake 6

Sickle Cell Disease Patients

For children with sickle cell disease:

• PONV is common after adenotonsillectomy and should be treated promptly 6
• Maintain adequate hydration until oral intake is fully re-established 6
• Use ondansetron for prevention of PONV 6

Clinical Impact and Importance

PONV in children is not merely a "big little problem" but a significant cause of:

• Dehydration and electrolyte imbalances
• Increased risk of bleeding at surgical sites
• Delayed discharge and unplanned hospital admissions
• Significant patient distress and parental dissatisfaction

Conclusion

The evidence clearly demonstrates that PONV in children is not acceptable and should be actively prevented and treated. A proactive, multimodal approach to PONV management significantly improves outcomes and patient experience. The most effective strategy combines risk assessment, anesthetic technique modification, and prophylactic antiemetic therapy tailored to the child's risk level.