Postoperative Nausea and Vomiting

Aka: Postoperative Nausea and Vomiting, Postoperative Nausea and Vomiting Prevention, PONV, Nausea After Surgery, Vomiting After Surgery

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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)

  1. 5-HT3 Receptor Antagonist (e.g. Ondansetron) with Dexamethasone
  2. 5-HT3 Receptor Antagonist (e.g. Ondansetron) with Droperidol

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]

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