University of Maryland Medical Center
Postoperative Nausea and Vomiting GuidelinesRationale
Postoperative nausea and vomiting (PONV) are frequent complications of surgeryand anesthesia. Currently the overall incidence of postoperative nausea and vomiting isestimated to be 25-30%.
PONV can lead to delayed postanesthesia care unit recoveryroom discharge, prolonged hospitalization, decreased patient satisfaction and increaseduse of resources. However, given that only 25-30% of patients actually experiencesPONV, routine prophylaxis for PONV is not indicated.The decision to use antiemetic prophylaxis should be based upon risk factors for nausea and vomiting and the potential for serious sequelae from vomiting.
A systematic search of a medical literature database (http://www.ncbi.nih.gov/entrez/query.fcgi) revealed several studies on PONV and risk models. Risk models thatwere identified and evaluated include Apfel et al, Gan et al, and Sinclair et al.
Inaddition, a comparative study of six models, including those previously identified wasevaluated. Furthermore, a query to the United Health System Consortium listserv elicitedseveral strategies for the control of postoperative nausea and vomiting. The University of Kentucky has also developed guidelines for the use of postoperative nausea andvomiting. However, these guidelines were created prior to the FDA black box warningfor droperidol.
Risk Factors for PONV
The risk factors associated with postoperative nausea and vomiting can beclassified as patient or operative.
The risk of PONV is higher in adults than in children, in women than in men, inobese patients, in patients who have high preoperative anxiety, and in patients with ahistory of PONV or motion sickness.The type of operative procedure can increase the rate of postoperative nausea andvomiting, such as intra-abdominal, major gynecological, orthopedic, ear-nose-throat,laparoscopic surgery, adenotonsil-lectomy, and surgery for strasbismus. Intubation mayalso cause nausea and vomiting.
Three 5HT3 receptor antagonists have been studied for use in patients for prevention of postoperative nausea and vomiting. Placebo-controlled trials havedemonstrated efficacy with ondansetron, dolasetron and granisetron.Ondansetron can be given as a 4 mg single IV dose at the induction of anesthesia.In two trials comparing ondansetron 4 mg IV the percentage of patients with no emeticepisodes were 76% and 63%, respectively. Both studies showed greater response than inthe placebo group.A pooled analysis of three trials determined that 12.5 mg of dolasetron given IVwas effective in the prevention of postoperative nausea and vomiting. Dolasetron 12.5mg, 25 mg, 50 mg, and 100 mg dolasetron doses were assessed for efficacy when given