Postoperative Nausea and Vomiting After Hartmann's Procedure
Yes, nausea and vomiting are common and expected complications in the immediate postoperative period after a Hartmann's procedure, occurring in 30-80% of patients without prophylaxis, but they should be actively prevented and treated with multimodal antiemetic therapy rather than simply accepted as "normal." 1, 2, 3
Risk Assessment
Patients undergoing Hartmann's procedure have multiple risk factors for postoperative nausea and vomiting (PONV):
- Major abdominal surgery itself is a significant risk factor 4
- Female gender (if applicable) adds one point to risk score 1
- Non-smoking status adds one point 1
- History of PONV or motion sickness adds one point 1
- Postoperative opioid use (nearly universal after this surgery) adds one point 1
- Use of volatile anesthetic agents during general anesthesia increases risk 4
Using the Apfel score, most Hartmann's patients will have ≥2 risk factors, placing them at moderate to high risk for PONV 1.
Prophylactic Management (What Should Have Been Done)
For patients with Apfel score ≥2, prophylactic antiemetic therapy with combination therapy from at least two different drug classes is strongly recommended 4, 1:
First-Line Combination Therapy
- Dexamethasone 4-8 mg IV at induction of anesthesia 4
- Plus a 5-HT3 receptor antagonist (ondansetron, granisetron, or ramosetron) at the end of surgery 4
For High-Risk Patients (≥3 Risk Factors)
Add a third agent from a different class 1:
- Droperidol 4
- Metoclopramide 25-50 mg given 30-60 minutes before end of surgery 4
- Neurokinin-1 receptor antagonist (aprepitant) 1
Anesthetic Modifications
- Use propofol-based total intravenous anesthesia (TIVA) instead of volatile anesthetics 1, 5, 6
- Avoid nitrous oxide 1
- Implement opioid-sparing multimodal analgesia (epidural, wound catheters, or TAP blocks) 4, 1
Treatment of Established PONV
If nausea and vomiting occur despite prophylaxis or if no prophylaxis was given:
Rescue Antiemetic Strategy
Use a different drug class than what was used for prophylaxis - using the same class significantly reduces effectiveness 1. Select from:
- 5-HT3 antagonists (ondansetron 4-8 mg IV) 3
- Corticosteroids (dexamethasone 4-8 mg IV) 3
- Dopamine antagonists (droperidol 0.625-1.25 mg IV, metoclopramide 10 mg IV) 3
- Antihistamines (promethazine 12.5-25 mg IV) 3
- Anticholinergics (scopolamine patch) 3
Fluid Management
- Ensure adequate hydration with mildly positive fluid balance at approximately 2 mL/kg/h 1, 7
- Avoid both dehydration and fluid overload 7
When to Escalate Concern
While PONV is common, persistent vomiting beyond 48 hours or presence of alarming signs requires urgent evaluation for surgical complications 7, 8:
Red Flags Requiring Immediate Assessment
- Tachycardia ≥110 bpm 7
- Fever ≥38°C 7
- Hypotension or respiratory distress 7
- Decreased urine output 7
- Severe abdominal pain or distension 7
These may indicate anastomotic leak, bowel obstruction, intestinal ischemia, or other serious complications requiring imaging (CT scan) and possible surgical intervention 7, 8.
Laboratory Evaluation
If symptoms persist or red flags present, obtain 7:
- Complete blood count
- Electrolytes
- C-reactive protein
- Serum lactate
Special Considerations
- If vomiting persists >2-3 weeks, administer thiamin supplementation to prevent Wernicke's encephalopathy 7, 8
- Monitor for dehydration and electrolyte abnormalities which can both result from and exacerbate PONV 7
- Early removal of nasogastric tube (day 1-2) with metoclopramide and early mobilization decreases PONV rates 4
Evidence Quality Note
High-certainty evidence supports the efficacy of ondansetron, granisetron, ramosetron, dexamethasone, and aprepitant for preventing vomiting 3. However, safety data (serious adverse events) for these drugs ranges from very low to low certainty 3. The multimodal approach recommended by ERAS Society guidelines represents strong consensus despite variable evidence quality 4.