Clinical Guideline

Postoperative nausea and vomiting (adults)

Postoperative nausea and vomiting (PONV) risk can be estimated by assessing 4 risk factors. This allows a quick and easy way to stratify a patients risk of PONV. NOTE: This guideline does not apply to pregnant women Step 1: Determining the risk of PONV For all surgical patients, a postoperative nausea and vomiting (PONV) risk score should be calculated. To do this, clinical staff must determine how many of the following risk factors apply to each patient: Female gender Non-smoker History of PONV or motion sickness Long-acting opioids (eg, morphine) administered during or after surgery This translates into a risk category: Number of risk factors 01 2 3 4

Risk category Low Medium High Very high

Probability of PONV 1020% 40% 60% 80%

Step 2: Prophylaxis of PONV in theatre These risk factors can be used to identify which patients should receive antiemetics prophylactically during surgery*: Number of risk factors 01 2 3 4 Suitable prophylaxis None required Cyclizine 50mg IV (slow bolus) Cyclizine 50mg IV (slow bolus), and Dexamethasone 4mg IV (slow bolus) Cyclizine 50mg IV (slow bolus), and Dexamethasone 4mg IV (slow bolus), and Consider total IV anaesthesia, omitting nitrous oxide, using a local or regional anaesthetic

For patients expected to have a postoperative PCA Cyclizine 50mg, by slow IV bolus, should be administered during the operation. *In some specialties (eg, hiatal surgery), patients should be given antiemetics regardless of risk factors.

Postoperative nausea and vomiting (adults) clinical guideline, V1 Approved by Medicines Clinical Guideline Sub-committee: February 2012

Principal author: Dr M van Miert Review by: February 2015 Page 1 of 4

Step 3: Treating established PONV in recovery Antiemetics should NOT be given to ALL patients in recovery only those who have not already received one in theatre. An appropriate antiemetic can be found below. If an antiemetic has already been used prophylactically, then a second antiemetic with a different mode of action should be used for treatment.

First line all patients Ondansetron 4mg, by slow IV bolus NOTE: Allow 30 minutes before trying an alternative antiemetic Second line For patients with 01 risk factors Cyclizine 50mg, by slow IV bolus Third line For patients with 01 risk factors Prochlorperazine 12.5mg, by IM injection

For patients with 2 or more risk factors Prochlorperazine 12.5mg, by IM injection

Step 4: Treating PONV on wards Depending on whether or not a patient has been issued with a PCA, one of the following order sets should be prescribed for all postoperative patients: A) If patient has been given a PCA (which contains cyclizine) First line Ondansetron 4mg, by slow IV bolus, every 6 hours when required NOTE: Allow 1 hour before trying the next antiemetic If ondansetron is ineffective Prochlorperazine 12.5mg, by IM injection, every 6 hours when required

B) If patient has NOT been given a PCA First line Ondansetron 4mg, by slow IV bolus, every 6 hours when required NOTE: Allow 1 hour before trying an alternative antiemetic If ondansetron is ineffective Cyclizine 50mg, by IM injection, every 8 hours when required If cyclizine is ineffective Prochlorperazine 12.5mg, by IM injection, every 6 hours when required NOTE: If an episode of nausea/vomiting develops after a patient starts eating post-op, this could be caused by a surgical condition (eg, ileus, bowel obstruction, acute gastric dilatation). For such patients, placement of a nasogastric tube might be more appropriate than antiemetic medicines.
Postoperative nausea and vomiting (adults) clinical guideline, V1 Approved by Medicines Clinical Guideline Sub-committee: February 2012 Principal author: Dr M van Miert Review by: February 2015 Page 2 of 4

Rationale for Guidelines Work by Apfel and colleagues1 suggests PONV risk can be estimated by assessing 4 risk factors. This allows a quick and easy way to stratify a patients risk of PONV. Since anti-emetics given prophylactically are of relatively limited efficacy, treating low-risk patients is of questionable value, with numbers needed to treat (NNT) approaching numbers need to harm (NNH). For example, for an Apfel score of 1 with a single anti-emetic, NNT=40; for ondansetron, NNH for a headache is 36, for constipation is 23, and for raised liver enzymes is 31.2 Consensus guidelines, produced in 2003,3 suggest treating only higher risk patients with prophylactic anti-emetics and using combination therapy for the highest risk patients. An audit performed at WUTH in 20084 shows we are poor at treating risk appropriately. We tend to give antiemetics to low-risk patients and not use combination therapy for the highest risk patients. Treating according to risk should result in better treatment and cost reduction. The rationale behind using cyclizine first line is that evidence suggests it is of comparable efficacy with ondansetron as a prophylactic treatment of PONV.5 Ondansetron has good evidence of efficacy in treating vomiting.6 There is no good evidence that cyclizine is an effective treatment of established PONV (theres no evidence that its not either theres just no evidence). It would be logical to reserve ondansetron for treating established PONV and use cyclizine primarily for prophylaxis. Combination prophylaxis using drugs from different classes is recommended in the 2003 consensus guidelines. Most published work looks at the combination of dexamethasone and ondansetron.5 Treating PONV in recovery First-line treatment should be using a drug from a different class to the prophylactic drug used. 5HT3 antagonists have the best evidence as treatments of established vomiting and should be used first line. Antiemetics should be used ONLY as rescue therapy in recovery. Currently, antiemetics are often given as prophylaxis when morphine is administered. Treating PONV on wards We have long had guidelines on treating PONV on wards. Antiemetics have shown to be efficacious by published audit data.7 These guidelines were produced when ondansetron was relatively expensive; this is no longer the case. Looking at the use of antiemetics on surgical wards, it appears prochlorperazine is used minimally despite being the first-line treatment and being more expensive than ondansetron and cyclizine. The relative usage appears to be a ratio of 1:2:6 (prochlorperazine: cyclizine: ondansetron). Since ondansetron has the best data for treating vomiting, it should be used first line, followed by cyclizine (in non-PCA patients) and then prochlorperazine.

Postoperative nausea and vomiting (adults) clinical guideline, V1 Approved by Medicines Clinical Guideline Sub-committee: February 2012

Principal author: Dr M van Miert Review by: February 2015 Page 3 of 4

Acknowledgement The design of the main table in these guidelines is based on one produced by K. Floss from Oxford Radcliffe Hospitals NHS Trust, Sept 2007.

References 1. Apfel CC, et al. A simplified risk score for predicting postoperative nausea and vomiting. Anesthesiology 1999;91:693700. 2. Kazemi-Kjellberg F, et al. Treatment of established postoperative nausea and vomiting: a quantitative systematic review. BMC Anesthesiology 2001;1:2. 3. Gan TJ, et al: Consensus guidelines for managing postoperative nausea and vomiting. Anesthesia & Analgesia 2003;97:6271. 4. Fanning J, van Miert MM. An audit of the use of the Apfel score for post-operative nausea and vomiting risk assessment. Poster presentation from AAGBI National Congress, 2008. 5. Carlisle J, et al. Drugs for preventing postoperative nausea and vomiting. Cochrane Database of Systematic Reviews 2006, Issue 3. 6. Tramr MR. Systematic reviews in PONV therapy. In: Tramr M (Ed.). Evidence Based Resource in Anaesthesia and Analgesia. London: BMJ Books; 2000: 15778. 7. Hadji F, et al: The impact of audit in a district general hospital on post-operative nausea and vomiting after major gynaecological surgery. European Journal of Anaesthesiology 1998;15:5959.

Postoperative nausea and vomiting (adults) clinical guideline, V1 Approved by Medicines Clinical Guideline Sub-committee: February 2012

Principal author: Dr M van Miert Review by: February 2015 Page 4 of 4