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Highlights
•
PONV baseline risk factors should be reduced whenever possible.
•Prophylactic and therapeutic antiemetics should be administered to patients as per their risk of developing PONV.
•For patients in whom prophylaxis failed, antiemetic treatment should be administered as soon as possible.
•Patients at high risk of developing Post-discharge Nausea and vomiting should be provided rescue treatment.
Abstract
Background
Postoperative nausea and vomiting is one of the common dissatisfying after surgery with a wide range of complications. It has an incidence of about 80% for patients with multiple risk factors. The etiologies of PONV are multifactorial including patient, anesthetic, and surgical factors. This review aims to support the clinical decision making of PONV management based on available evidence.
Methods
Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol was used to conduct this study. PubMed, Cochrane library, and Google Scholar search engines were used to find evidence that helps to draw recommendations and conclusions.
Results
In this systemic review and guideline we had used five systemic review and Meta-analysis, one guideline and 4 Meta-analysis of RCTs, three Literature reviews, three Multicenter RCTs, thirteen Single-center RCTs, and two Cross-sectional studies with their respective description of studies.
Discussion
In the presence of persistent nausea and vomiting, possible contributing factors, such as patient-controlled morphine analgesia, presence of blood in the pharynx, or an abdominal obstruction, hypotension, hypoxia should be excluded before rescue therapy may be initiated.
Conclusions
Patients who came for surgery have to be evaluated for the risk factors PONV and they should be categorized as low or high risk of it based on the APFEL risk score. Prevention and management of PONV should follow the flow chart as evidenced by most of the literature.
Keywords
Prevention
PONV
Prophylaxis
Cited by [0]
© 2020 The Author[s]. Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
This guideline is aimed at providing quick and general guideline on PONV. Refer to local protocols for more detailed guidance.
Nausea and vomiting is a common and distressing symptom or side effect in medicine, surgery and following anaesthesia. It can cause complications such as wound dehiscence, electrolyte imbalance, increased pain, dehydration and aspiration. Generally, uncomplicated PONV rarely goes beyond 24 hours post-operatively. Problematic PONV however is more multifactorial in origin and can be difficult to treat effectively. Patients at risk of this should be identified by the anaesthetist and may be given prophylactic anti-emetic treatment. Post-operative patients with nausea and vomiting may be considered as either failure of prophylaxis or for primary treatment.
Drug therapy
The table below is a general quick guide on the prescribing of anti-emetics, but see local guidelines.
| Anti-emetic / Site of action | Dose and route of administration | Comments |
Ondansetron 5HT3 receptor antagonist | 4mg oral / IV every 8 hours | Risk of prolonged QT interval, constipation. Avoid if congenital long QT syndrome. |
Prochlorperazine Medullary chemoreceptor zone Dopamine [D2] receptor antagonist | 3–6mg buccal every 12 hours or 12.5mg deep IM as a 'one-off' dose [IM route only, not by other parenteral routes]. In elderly patients - 3mg buccal every 12 hours or 6.25mg IM as a 'one-off' dose. | Extrapyramidal side effects - dystonic reaction. Dose reduce in elderly patients due to increased susceptibility to hypotension and neuromuscular reactions. |
Cyclizine Acts on vomiting centre. Histamine [H1] receptor antagonist | 50mg oral/IM/IV every 8 hours. Avoid oral route if actively vomiting. In elderly patients - 25mg every 8 hours. | Avoid in severe heart failure, porphyria. |
Dexamethasone Site of action unknown | 4mg IV/IM single dose | Restricted for use by the acute pain team, on-call anaesthetist. Caution - acute rectal pain with IV administration. It is not licensed for PONV. |
Droperidol Mainly dopaminergic receptor antagonist in chemoreceptor trigger zone | IV dose varies – see BNF for guidance | Restricted to use by consultant anaesthetists. Third-line agent for PONV if unresponsive to other anti-emetics. Risk of QT interval prolongation. |
| N.B. The side effects, cautions and contraindications mentioned in the comments section are not exhaustive. See BNF or Summary of Product Characteristics for further information. |
General notes
- Ondansetron may be used as a first-line option, consider the comments section in the table above.
- Prochlorperazine can cause extrapyramidal side effects and may not be the best choice in certain patients. Seek senior advice. It is important to note that IM doses should only be given as a 'one off' dose.
- Cyclizine parenterally may be given if ondansetron [first-line choice] or prochlorperazine are not appropriate.
- If, after regular routine observation and assessment, it is apparent that one anti-emetic is ineffective, add in another. Use one which acts by a different mechanism as a combination of two anti-emetic drugs acting at different sites may be more effective in resistant PONV [see table above].
- If it is not possible to stop opioid analgesia, consider change of opioid, and remember to prescribe simple analgesics and NSAIDs where possible. See acute pain guideline.
- For choice of anti-emetic in breastfeeding or pregnant women contact your clinical pharmacist for advice or Medicines Information department [see Appendix 6 for contact details].
- In elderly patients [>70 years] use lower doses of prochlorperazine and cyclizine [see table above].
- Intractable vomiting may have a surgical / other serious underlying cause. Senior review is recommended.
Other information
- Metoclopramide is ineffective as an anti-emetic for PONV in licensed dosage and should not be prescribed as a routine anti-emetic unless gastric stasis is the cause of the nausea. Restrict use in young adults under 20 years [especially women] to certain circumstances because of the risk of extrapyramidal side effects. Seek senior / specialist advice if necessary.
- Metoclopramide is contraindicated in gastrointestinal obstruction and should be avoided post-gastrointestinal surgery.