What is the management for nausea and vomiting post thyroidectomy?

Management of Nausea and Vomiting Post Thyroidectomy

Dexamethasone 8 mg IV administered preoperatively is the most effective first-line intervention for preventing postoperative nausea and vomiting (PONV) after thyroidectomy. 1

Risk Factors and Incidence

• Thyroidectomy is associated with a high incidence of PONV, especially in female patients 2, 3
• Common risk factors include female gender, history of PONV or motion sickness, non-smoking status, and use of volatile anesthetics or opioids 1

Preventive Strategies

First-Line Pharmacological Prevention

• Corticosteroids:

  • Dexamethasone 8 mg IV administered preoperatively significantly reduces the incidence and severity of PONV (P = .001) 1
  • A single preoperative dose also reduces postoperative pain (P = .008) 1
  • A 4-5 mg dose may be as effective as 8-10 mg for PONV prevention 4

• 5-HT3 Receptor Antagonists:

  • Ondansetron 4 mg IV is FDA-approved for PONV prevention in patients ≥1 month old 5
  • Granisetron 3 mg IV has shown superior efficacy compared to metoclopramide and droperidol, with complete response rates of 90% in the first 3 hours post-thyroidectomy 6
  • Ramosetron 0.3 mg IV at the end of surgery reduces PONV incidence, especially during the first 6 hours postoperatively 7

Anesthetic Technique Considerations

• Total intravenous anesthesia (TIVA) with propofol-remifentanil is associated with significantly lower PONV rates compared to sevoflurane-based balanced anesthesia (14.6% vs 51.3%) 8

Treatment of Established PONV

Pharmacological Management

• For breakthrough PONV, use a different class of antiemetic than was used for prophylaxis: 1

  • Dopamine receptor antagonists: metoclopramide, prochlorperazine, or haloperidol 1
  • 5-HT3 receptor antagonists: ondansetron 4 mg IV (if not already used for prophylaxis) 1, 5
  • Anticholinergics or antihistamines can be added for persistent nausea 1

• For persistent or intractable PONV:

  • Consider continuous infusion of antiemetics 1
  • Combination therapy using medications from different classes is more effective than single-agent therapy 1

Multimodal Approach

• Combining dexamethasone with a 5-HT3 antagonist provides significantly greater efficacy than either agent alone 4
• For high-risk patients (multiple risk factors), use 2-3 antiemetics from different classes 1
• Adequate hydration and minimizing opioid use can further reduce PONV risk 1

Important Considerations and Pitfalls

• Avoid using the same antiemetic class for both prophylaxis and rescue therapy as this reduces effectiveness 1
• While dexamethasone is effective for PONV, potential adverse effects including hyperglycemia, infection, and delayed wound healing should be monitored, though these complications were not reported in thyroidectomy studies 1
• Routine assessment and monitoring of nausea and vomiting should be performed during emergence and recovery to detect complications early 1