Postoperative Nausea and Vomiting Management

Introduction to PONV Prophylaxis

A multimodal approach using at least two antiemetic drugs from different classes should be used for postoperative nausea and vomiting (PONV) prophylaxis, with medication selection based on patient risk factors, as recommended by the World Journal of Emergency Surgery guidelines and the American College of Surgeons 1, 2
High-risk patients (≥3 risk factors) should receive a combination of dexamethasone, a serotonin receptor antagonist, and droperidol or metoclopramide, according to the Clinical Nutrition guidelines and the American College of Obstetricians and Gynecologists 3, 4

Patients with 0-1 risk factors may be considered for single antiemetic prophylaxis, while those with 1-2 risk factors should receive a two-drug combination, and those with ≥2 risk factors should receive a three-drug combination, based on general medical knowledge and recommended by the American College of Surgeons and the World Health Organization 2, 5
The Apfel Score, which considers female gender, non-smoking status, history of PONV or motion sickness, and expected postoperative opioid use, should be used to assess patient risk factors and guide a risk-based prophylaxis approach, as recommended by the American College of Surgeons 2
Dexamethasone 4-8 mg IV at the beginning of surgery, plus a serotonin receptor antagonist at the end of surgery, and droperidol or metoclopramide 25-50 mg 30-60 minutes before the end of surgery, is recommended for high-risk patients, as per the Clinical Nutrition guidelines and the American College of Obstetricians and Gynecologists 3, 4

Minimizing opioid use through multimodal analgesia approaches, ensuring adequate hydration, correcting electrolyte abnormalities, and considering total intravenous anesthesia (TIVA) with propofol instead of volatile anesthetics, can help reduce PONV incidence, as recommended by the World Journal of Emergency Surgery guidelines and the American Society of Anesthesiologists 1, 4
Early mobilization from the operative day until hospital discharge is also recommended, according to the World Journal of Emergency Surgery guidelines 1, 6
Fluid preloading can reduce the incidence of hypotension-related nausea, as suggested by the American College of Obstetricians and Gynecologists 4

The following antiemetics are effective for PONV prophylaxis:
First-line therapy should include ondansetron 4mg IV + dexamethasone 8mg IV, as recommended by the American College of Obstetricians and Gynecologists 4

Elderly patients should use lower doses of benzodiazepines, and patients with electrolyte abnormalities or cardiac conditions should be monitored with ECG when using certain antiemetics, such as droperidol, according to general medical knowledge and the American College of Obstetricians and Gynecologists 7, 4
Pregnant patients can benefit from tropisetron 2mg and metoclopramide 20mg for cesarean delivery, as recommended by the American College of Obstetricians and Gynecologists 4

Administering rescue medication from a different class than those used for prophylaxis is recommended, such as promethazine, droperidol, or metoclopramide 10mg IV, according to the World Journal of Emergency Surgery and the American College of Obstetricians and Gynecologists 2, 4
If PONV occurs despite prophylaxis, rescue medication should be from a different class than those used for prophylaxis, such as promethazine or droperidol, and if there is an inadequate response, add metoclopramide 10mg IV or droperidol, as suggested by the American College of Obstetricians and Gynecologists 4
For persistent symptoms, add scopolamine transdermal patch, according to the American College of Obstetricians and Gynecologists 4
Around-the-clock administration of antiemetics is more effective than as-needed dosing, as suggested by the National Comprehensive Cancer Network 8
Monotherapy using a single antiemetic agent is often inadequate for high-risk patients undergoing surgery, according to the American College of Obstetricians and Gynecologists, and delayed treatment, administering antiemetics only after symptoms appear rather than prophylactically, is not recommended 4