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Saturday June 21st, 2003 |
From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA.
Address correspondence to: Dr. Tong J. Gan, Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710, USA. Phone: 919-681-4660; Fax: 919-681-7901; E-mail: gan00001{at}mc.duke.edu.
POSTOPERATIVE nausea and vomiting (PONV) is one of the most common complications following surgery. Prior to the 1960s, when older inhalational agents such as ether and cyclopropane were widely used, the incidence of vomiting was reported to be as high as 60%.1,2 Better anesthetic techniques, along with a new generation of antiemetics and shorter acting anesthetic drugs, reduced the incidence of PONV to about 30% in today’s practice. Nevertheless, PONV still occurs, with an incidence as high as 60–70% in some high-risk patients.3,4 Pediatric populations are not spared from PONV. While the incidence may be lower in children less than two years of age,5,6 some procedures, tonsillectomies and strabismus surgery, are associated with high incidence of PONV.7,8 Ambulatory patients appear to have lower incidence of PONV compared with in-patients,9 but this could be related to the fact that postdischarge nausea and vomiting are not recognized. While PONV is rarely fatal, it is considered one of the most unpleasant postoperative symptoms. Even mild PONV may result in delayed hospital discharge, decreased patient satisfaction and increased use of resources, including medical and nursing care and other supplies.10 Avoiding PONV is very important to patients. They rated avoiding PONV more important than avoiding pain postoperatively.11 Patients are willing to spend up to US $100 out of their pocket for an effective antiemetic.12
Consensus guidelines on PONV management
The management of PONV is complex and there is literature supporting the use of every antiemetic available in practice. Hence, it is often difficult for practitioners to adopt an evidence-based practice for PONV management. Recently, a multidisciplinary panel of experts convened to review the medical literature on PONV and to produce guidelines for the management PONV.13 The panel consulted the medical literature for level of evidence rating scales that were pertinent and widely used, then adapted them to the body of scientific literature relating to PONV.14,15 In the absence of published data, recommendations were made on the basis of expert opinion. The following scales were used in rating the guidelines:
Level of evidence based on study design
100 per group
Strength of recommendation based on expert opinion
The aim of this scale was to present information on both the design and the source of the data (I to V) independent of the validity of those data. The quality of the data was judged by the panel, which determined whether the recommendation was good, fair, or insufficient. For instance, a logistic regression analysis that aims to identify risk factors for PONV would fall into level IV since such trials are not randomized. However, information emerging from that study may be judged as "A" by the panel.
Identification of patients at high risk for PONV enables targeting prophylaxis to those who will benefit most from it. Universal PONV prophylaxis is not cost effective, is unlikely to benefit patients at low risk for PONV and would put them at risk from the potential side effects of antiemetic agents. Patient, anesthesia, and surgery related risk factors have been identified (Guideline 1). Anesthesia related risk factors include the use of volatile agents, which cause PONV during the early postoperative period (within 0–2 hr),16 nitrous oxide,17 opioids3,16 and high doses of neostigmine (> 2.5 mg) for the reversal of neuromuscular blockade.15 Patient related factors include female gender,3,18 history of PONV or motion sickness3,18,19 and non-smoking status.3,19 High levels of anxiety and postoperative pain, especially of pelvic or visceral origin, may also be associated with a higher incidence of PONV.20–22
According to a recent consensus panel, obesity and the stage of the menstrual cycle do not increase the risk of PONV.13 Long surgical procedures (each 30 min increase in duration increases PONV risk by about 60 %)18 and certain types of surgery also carry a greater risk of PONV.4,18,23 In adults, high incidences of PONV are found in intra-abdominal surgery, major gynecological surgery, laparoscopic surgery, breast surgery, neurosurgery, eye and otorhinolaryngology (ENT) surgery. Pediatric operations at high risk for PONV include strabismus, adenotonsillectomy, hernia repair, orchidopexy, penile surgery and middle ear procedures.24,25 Some authors, however, could not demonstrate an association between type of surgery and the risk of PONV.3 The incidence of PONV increases after the age of three years with a peak incidence of about 40% in the 11–14 yr age group.3,25,26 Prior to puberty, gender differences for PONV have not been identified.13
In a study of 2,722 patients, Apfel et al. developed a simplified risk score consisting of four predictors: female gender, history of motion sickness or PONV, non-smoking status and the use of opioids for postoperative analgesia. If none, one, two, three or four of these risk factors were present, the incidences of PONV were ten, 21, 39, 61 and 79% respectively.3
Guideline I. Identify adults at high risk for PONV
Patient-specific risk factors
Anesthetic risk factors
Surgical risk factors
Guideline II. Identify children at high risk for postoperative vomiting (POV)
Risk factors for POV in children are similar to those in adults, with the following differences:
Guideline III. Reduce baseline risk factors for PONV
Approaches for lowering baseline risk factors include:
Guideline IV. Antiemetic therapy for PONV prophylaxis in adults
Serotonin (5-HT3) antagonists
-Ondansetron (IA)
-Dolasetron (IA)
-Granisetron (IA)
-Tropisetron (IA)
Dexamethasone (IIA)
Droperidol (IA)
Dimenhydrinate (IIA)
Ephedrine (IIIB)
Prochlorperazine (IIIA)
Promethazine (IIIB)
Transdermal scopolamine (IIB)
Nonpharmacologic techniques
Acupuncture (IIA)
Hypnosis (IIIB)
Guideline V Antiemetic doses for children
Agent Dose Evidence
Ondansetron 50–100 µg•kg –1 up to 4 mg IIA
Dolasetron 350 µg•kg –1 up to 12.5 mg V
Dexamethasone 150 µg•kg–1 up to 8 mg IA
Droperidol 50 – 75 µg•kg–1 up to 1.25 mg IIA
Dimenhydrinate 0.5 mg•kg–1 IIA
Perphenazine 70 µg•kg–1 IA
Guideline VI Antiemetic treatment for patients with PONV who did not receive prophylaxis or in whom prophylaxis failed
Rule out inciting medication or mechanical causes of PONV (V)
Initial therapy
Failed prophylaxis
Use agent from different class (V) or propofol, 20 mg prn (adults; IIIB)
*Low-dose 5-HT antagonist dosing: ondansetron 1.0 mg; dolasetron 12.5 mg; granisetron 0.1 mg; tropisetron 0.5 mg; **Alternative therapies for rescue: droperidol 0.5 mg iv; dexamethasone (2–4 mg iv); promethazine 12.5 mg iv.
Conclusion
While we have achieved significant advances in the management of PONV, it still occurs frequently in high-risk patients. These guidelines provide a comprehensive, evidence-based reference tool for the management of patients at risk for PONV. Not all surgical patients will benefit from antiemetic prophylaxis, thus identification of patients who are at increased risk is imperative. The major risk factors for PONV are: female gender, non-smoking status, history of PONV/motion sickness, use of volatile anesthetics, nitrous oxide, intraoperative and postoperative opioids, increased duration of surgery, and type of surgery (laparoscopy, ENT, neurosurgery, breast, strabismus, laparotomy, plastic surgery).
The first step in reducing PONV risk is to reduce baseline risk factors among patients at risk (Figure
). There is increasing evidence that the combination of several potentially beneficial factors (multimodal approach) may lead to an improved outcome.
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