II. Epidemiology

  1. Incidence of Postoperative Nausea and Vomiting (PONV): 30% (70% in high risk patients)

III. Pathophysiology

  1. See Vomiting
  2. Images
    1. vomitingPathway.png

IV. Risk factors

  1. Patient characteristics with higher risk of Postoperative Nausea and Vomiting (PONV)
    1. Female gender
    2. History of Motion Sickness
    3. Prior episode Postoperative Nausea and Vomiting
    4. Non-smokers
    5. Postoperative use of opiod Analgesics
  2. Surgeries with higher PONV risk
    1. Craniotomy
    2. Ear, nose and throat surgery
    3. Major Breast surgery
    4. Laparoscopy or Laparotomy
    5. Strabismus surgery
    6. Cholecystectomy
    7. Bariatric Surgery
    8. Gynecologic Surgery
  3. Anesthetics with higher PONV risk
    1. Opiod Analgesics
    2. Nitrous Oxide
    3. Volatile inhalational Anesthetics

V. Management: Medications

  1. Scopolamine Transdermal
  2. Dimehydrinate
  3. 5-HT3 Receptor Antagonist
    1. Ondansetron
    2. Granisetron
    3. Palonosetron
  4. Dopamine Receptor Antagonist
    1. Droperidol
    2. Amisulpride (Barhemsys)
    3. Haloperidol
      1. May use as alternative to Droperidol
      2. Give 0.5 to 1 mg IM or IV at Anesthesia induction or end of surgery
    4. Metoclopramide
      1. Less effective for PONV than other options (e.g. Ondansetron)
  5. Phenothiazines (Limited evidence of efficacy in PONV)
    1. Promethazine (Phenergan)
    2. Prochlorperazine (Compazine)
  6. NK1 Receptor Antagonist (given before surgery)
    1. Aprepitant
    2. Rolipitant

VI. Prevention: Mild Risk of PONV (1-2 risk factors)

  1. Dexamethasone
    1. Give 4 to 8 mg IV once for single dose at Anesthesia induction
    2. Not effective for treatment once Nausea, Vomiting is present
  2. Scopolamine Transdermal 1 mg patch
    1. Apply on the evening before surgery (at least 2 hours before induction)
    2. Remove 24 hours after surgery (may be kept in place for up to 72 hours)
  3. 5-HT3 Receptor Antagonist (e.g. Ondansetron, Granisetron)
    1. Ondansetron 4 mg IV given in last 20 min of surgery
  4. Droperidol (Inapsine)
    1. Not recommended as first line due to QT Prolongation
      1. However, EKG and monitoring precautions only apply for doses >= 2.5 mg IV/IM
    2. Combination given at end of surgery or within 20 min of Anesthesia
      1. Droperidol 0.625 to 1.25 mg IV and
      2. Dexamethasone 4 mg IV

VII. Prevention: Moderate Risk of PONV (3-4 risk factors)

VIII. Prevention: High Risk of PONV (>4 risk factors)

  1. Combination agents in Mild to Moderate risk list above AND
  2. Total intravenous Anesthesia with Propofol AND
  3. High concentration oxygen (80%) intraoperatively

IX. References

  1. (2023) Postoperative Nausea and Vomiting Management, Presc Lett, #390431
  2. (2020) Med Lett Drugs Ther 62(1614): 205-7 [PubMed]
  3. Gan (2002) JAMA 287:1233-6 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Postoperative Nausea and Vomiting (C0520909)

Definition (MSH) Emesis and queasiness occurring after anesthesia.
Concepts Sign or Symptom (T184)
MSH D020250
SnomedCT 1488000
Swedish Postoperativ illamående och kräkning
English POSTOP NAUSEA VOMITING, NAUSEA VOMITING POSTOP, PONV - Postop nausea+vomiting, Postoperative nausea+vomiting, Nausea and Vomiting, Postoperative, Postoperative Nausea and Vomiting, PONV, Postoperative Nausea and Vomiting [Disease/Finding], ponv, postoperative nausea and vomiting (PONV), Postoperative nausea and vomiting, PONV - Postoperative nausea and vomiting, Postoperative nausea and vomiting (disorder)
Czech pooperační nevolnost a zvracení
Finnish Leikkauksenjälkeinen pahoinvointi ja oksentaminen
Russian POSLEOPERATSIONNAIA TOSHNOTA I RVOTA, RVOTA POSLEOPERATSIONNAIA, TOSHNOTA I RVOTA POSLEOPERATSIONNAIA, ПОСЛЕОПЕРАЦИОННАЯ ТОШНОТА И РВОТА, РВОТА ПОСЛЕОПЕРАЦИОННАЯ, ТОШНОТА И РВОТА ПОСЛЕОПЕРАЦИОННАЯ
Japanese 悪心・嘔吐-手術後, 手術後悪心, 手術後嘔吐, 手術後悪心と手術後嘔吐, 術後悪心, 悪心・嘔吐-術後, 嘔吐-術後, 悪心-手術後, 手術後悪心・嘔吐, 悪心-術後, 術後嘔吐, 嘔吐-手術後, 術後悪心・嘔吐
Spanish Náuseas y Vómitos Postoperatorios, Náusea y Vómito Postquirúrgico, Náuseas y Vómitos Postquirúrgicos, náuseas y vómitos posoperatorios, náuseas y vómitos posquirúrgicos, náuseas y vómitos postoperatorios (trastorno), náuseas y vómitos postoperatorios, NVPO, Náusea y Vómito Postoperatorio
Italian PONV, Nausea e vomito postoperatorio
Polish PONV, Nudności i wymioty pooperacyjne
Norwegian Postoperativ kvalme og oppkast, Kvalme og oppkast etter operasjon
Croatian Postoperativna mučnina i povraćanje
French Vomissements et nausées postopératoires, Vomissements et nausées post-opératoires
German Postoperative Übelkeit und Erbrechen, Übelkeit und Erbrechen, postoperatives
Dutch Misselijkheid en braken, postoperatieve, PONV, Postoperatieve misselijkheid en braken
Portuguese PONV, Náusea e Vômito Pós-Operatório