Prophylaxis of postoperative nausea and vomiting in adults

Gan, 2020

Prophylaxis of postoperative nausea and vomiting (PONV) is indicated for patients at increased risk of PONV and patients at risk of medical sequelae from vomiting (eg patients with a wired jaw or raised intracranial pressure). Risk factors for PONV are listed in Risk factors for postoperative nausea and vomiting in adults. The incidence of PONV increases with the number of risk factors.

Table 1. Risk factors for postoperative nausea and vomiting in adults

Primary risk factors

Other risk factors

Patient risk factors
  • female sex
  • nonsmoking
  • history of PONV or motion sickness
  • younger than 50 years

Anaesthetic risk factors
  • postoperative opioid drugs
  • volatile anaesthetics
  • nitrous oxide
  • general anaesthesia
  • inadequate hydration

Surgical risk factors
  • longer duration of surgery
  • type of surgery (cholecystectomy, laparoscopic, gynaecological)

If possible, modify baseline risk factors (see Risk factors for postoperative nausea and vomiting in adults) to reduce the incidence of PONV. For example:

  • minimise anaesthetic risk factors (eg consider using propofol total intravenous anaesthesia or regional anaesthesia, and avoid volatile anaesthetic drugs and nitrous oxide)
  • optimise use of nonopioid analgesia (eg intravenous paracetamol, nonsteroidal anti-inflammatory drugs [NSAIDs], gabapentinoids, alpha2-adrenergic agonists)
  • ensure adequate hydration in the perioperative period.

The choice of prophylactic antiemetic regimen depends on how many risk factors for PONV are present (see Risk factors for postoperative nausea and vomiting in adults); therefore, it is important to conduct a risk-based assessment of all patients. Also consider the adverse effect profile of the antiemetic and the patient’s comorbidities. Combination drug therapy (using antiemetics with different mechanisms of action) is superior to monotherapy in preventing PONV.

Patients without any primary risk factors for PONV (see Risk factors for postoperative nausea and vomiting in adults) are at low risk of PONV and may not require prophylaxis with antiemetic drugs. However, patients should be given PONV prophylaxis regardless of risk factors if the patient is:

  • undergoing surgery where PONV could lead to adverse outcomes (eg cerebrovascular surgery, surgery where there is limited airway access)
  • on an enhanced recovery program.

If a patient has 1 or 2 primary risk factors for PONV (see Risk factors for postoperative nausea and vomiting in adults), use one or two of the following antiemetic drugs for prophylaxis:

a 5-HT3–receptor antagonist intravenously1

1granisetron 1 mg intravenously, as a single dose at the end of anaesthesia granisetron granisetron granisetron

OR

1ondansetron 4 mg intravenously, as a single dose at the end of anaesthesia ondansetron ondansetron ondansetron

OR

1palonosetron 0.075 mg intravenously, as a single dose at the end of anaesthesia2 palonosetron palonosetron palonosetron

OR

1tropisetron 2 mg intravenously, as a single dose at the end of anaesthesia tropisetron tropisetron tropisetron

OR

1dexamethasone 4 mg intravenously, as a single dose at the start of anaesthesia dexamethasone dexamethasone dexamethasone

OR

1droperidol 0.5 to 0.625 mg intravenously, as a single dose at the end of anaesthesia. droperidol droperidol droperidol

If a patient has 3 or more primary risk factors for PONV (see Risk factors for postoperative nausea and vomiting in adults), use combination therapy with at least 2 of the antiemetic drugs listed above. Ensure baseline risk factors are minimised (see above) and consider anxiolytic therapy—seek expert advice.

If the above regimens are inappropriate, or were previously ineffective, seek expert advice—aprepitant or cyclizine may be alternatives, if available. If a prophylactic regimen was previously ineffective, review whether the regimen used was appropriate for the patient’s risk profile or if PONV risk factors can be modified.

1 All 5-HT3–receptor antagonists should be given by intravenous injection over at least 30 seconds or by intravenous infusion in compatible fluid.Return
2 Palonosetron has a long duration of action and may be preferred for nausea and vomiting prophylaxis for high-risk patients.Return