Prevention and Treatment of Postoperative Nausea and Vomiting
Prevention and Treatment of Postoperative Nausea and Vomiting
Purpose: The physiology, risk factors, and prevention and treatment of postoperative nausea and vomiting (PONV) are discussed.
Summary: Factors to consider when determining a patient's risk for PONV include sex, history of PONV, history of motion sickness, smoking status, duration of anesthesia, use of opioids, and type of surgery. Receptors that, when activated, can cause nausea or vomiting or both include dopamine type 2, serotonin type 3, histamine type 1, and muscarinic cholinergic type 1 receptors. Patients at moderate to high risk for PONV benefit from the administration of a prophylactic antiemetic agent that blocks one or more of these receptors. Effective agents include transdermal scopolamine, prochlorperazine, promethazine, droperidol, ondansetron, dolasetron, granisetron, and dexamethasone. In high-risk patients, combining two or more antiemetics with different mechanisms of action has been shown to be more effective than using a single agent. In addition to administering a prophylactic antiemetic, it is important to reduce the patient's risk by considering regional anesthesia, considering inducing and maintaining general anesthesia with propofol, ensuring good intravenous hydration, avoiding hypotension, and providing effective analgesia. If PONV occurs in the immediate postoperative period, it is best treated with an antiemetic agent from a pharmacologic class different from that of the prophylactic agent.
Conclusion: Prophylactic antiemetic therapy for PONV is effective, but combinations of agents may be necessary for high-risk patients. Nonpharmacologic strategies are also important.
Postoperative nausea and vomiting (PONV) continues to be a highly undesirable outcome of anesthesia and surgery. For example, in the ambulatory care surgery setting, PONV is among the most common complications, with a frequency ranging from 30% to 50%. In this population, not only is recovery prolonged, but the patient is not under direct medical supervision for treatment of these undesirable sequelae. In addition, significant or uncontrolled PONV in the ambulatory surgery postanesthesia care unit can lead to unanticipated hospital admission. Persistent vomiting may result in electrolyte abnormalities and dehydration. Persistent retching or vomiting following surgery can put tension on suture lines, cause hematomas beneath surgical flaps, and place the patient at risk for pulmonary aspiration of vomit if airway reflexes are depressed from the lingering effects of anesthetic and analgesic drugs. With all this in mind, health care practitioners should strive for the best methods to prevent and treat PONV in a manner that addresses patient needs and is cost efficient.
This article discusses the physiology, risk factors, and prevention and treatment of PONV.
Purpose: The physiology, risk factors, and prevention and treatment of postoperative nausea and vomiting (PONV) are discussed.
Summary: Factors to consider when determining a patient's risk for PONV include sex, history of PONV, history of motion sickness, smoking status, duration of anesthesia, use of opioids, and type of surgery. Receptors that, when activated, can cause nausea or vomiting or both include dopamine type 2, serotonin type 3, histamine type 1, and muscarinic cholinergic type 1 receptors. Patients at moderate to high risk for PONV benefit from the administration of a prophylactic antiemetic agent that blocks one or more of these receptors. Effective agents include transdermal scopolamine, prochlorperazine, promethazine, droperidol, ondansetron, dolasetron, granisetron, and dexamethasone. In high-risk patients, combining two or more antiemetics with different mechanisms of action has been shown to be more effective than using a single agent. In addition to administering a prophylactic antiemetic, it is important to reduce the patient's risk by considering regional anesthesia, considering inducing and maintaining general anesthesia with propofol, ensuring good intravenous hydration, avoiding hypotension, and providing effective analgesia. If PONV occurs in the immediate postoperative period, it is best treated with an antiemetic agent from a pharmacologic class different from that of the prophylactic agent.
Conclusion: Prophylactic antiemetic therapy for PONV is effective, but combinations of agents may be necessary for high-risk patients. Nonpharmacologic strategies are also important.
Postoperative nausea and vomiting (PONV) continues to be a highly undesirable outcome of anesthesia and surgery. For example, in the ambulatory care surgery setting, PONV is among the most common complications, with a frequency ranging from 30% to 50%. In this population, not only is recovery prolonged, but the patient is not under direct medical supervision for treatment of these undesirable sequelae. In addition, significant or uncontrolled PONV in the ambulatory surgery postanesthesia care unit can lead to unanticipated hospital admission. Persistent vomiting may result in electrolyte abnormalities and dehydration. Persistent retching or vomiting following surgery can put tension on suture lines, cause hematomas beneath surgical flaps, and place the patient at risk for pulmonary aspiration of vomit if airway reflexes are depressed from the lingering effects of anesthetic and analgesic drugs. With all this in mind, health care practitioners should strive for the best methods to prevent and treat PONV in a manner that addresses patient needs and is cost efficient.
This article discusses the physiology, risk factors, and prevention and treatment of PONV.
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