What is the management of postoperative nausea and vomiting (PONV)?

From the Guidelines

Postoperative nausea and vomiting (PONV) management involves a multimodal approach. The most effective strategy includes the use of multiple antiemetic agents, such as 5-HT3 antagonists (e.g., ondansetron, granisetron), dopamine antagonists (e.g., metoclopramide, droperidol), and corticosteroids (e.g., dexamethasone) 1.

Key Components of PONV Management

• Risk assessment: All patients should undergo a risk assessment for PONV using scoring systems like the Apfel score 1.
• Prophylactic antiemetics: Patients with a high risk of PONV should receive a combination of two or three antiemetic drugs as prophylaxis 1.
• Multimodal approach: A multimodal approach, including total intravenous anesthesia (TIVA) and multimodal analgesia, can help reduce PONV 1.
• Rescue therapy: If PONV persists despite adequate prophylaxis, a different class of antiemetic should be used 1.

Recommended Antiemetic Agents

• 5-HT3 antagonists: Ondansetron, granisetron 1
• Dopamine antagonists: Metoclopramide, droperidol 1
• Corticosteroids: Dexamethasone (4-5 mg dose) 1
• Other options: Antihistamines, anticholinergics, and neurokinin-1 (NK1) receptor antagonists may also be used, but their use may be limited by side effects 1.

Additional Measures

• Prophylactic analgesia: Intravenous paracetamol (acetaminophen) can help reduce PONV 1
• Alternative therapies: Music therapy, aromatherapy, acupuncture, hypnosis, and relaxation techniques may also be beneficial in reducing PONV 1

From the Research

Management of Postoperative Nausea and Vomiting (PONV)

The management of PONV involves a multifaceted approach, including:

• Risk assessment using scoring systems such as the Apfel simplified scoring system 2
• Multimodal risk reduction strategies, including pharmacological and nonpharmacological interventions 3, 4
• Prophylactic measures, such as the use of antiemetic drugs with different mechanisms of action 2, 3, 5, 4, 6
• Prompt rescue treatment for established PONV, using a different antiemetic agent than the one used for prophylaxis 3

Pharmacological Prophylaxis

Pharmacological prophylaxis for PONV may include:

• Serotonin (5-hydroxytryptamine subtype 3) receptor antagonists 2
• Corticosteroids 2
• Anticholinergics 2
• Antihistaminics 2
• Butyrophenones 2
• Neurokinin-1 receptor antagonists, such as aprepitant 2, 5
• Newer antiemetic agents, such as amisulpride 5

Nonpharmacological Interventions

Nonpharmacological interventions for PONV may include:

• Adequate hydration 4
• Opioid-sparing multimodal analgesic techniques 4
• Nonpharmacologic antiemetic techniques 4

Special Considerations

Special considerations for PONV management include:

• Patient risk factors, such as history of PONV or motion sickness 3
• Surgical factors, such as type and duration of surgery 3
• Anesthesia-related factors, such as use of volatile anesthetics or nitrous oxide 3
• Postdischarge nausea and vomiting (PDNV) prevention and treatment 4