Postoperative Nausea and Vomiting Prophylaxis

Quick Answer

Postoperative nausea and vomiting (PONV) affects 20-30% of surgical patients and 70-80% of high-risk patients, significantly impacting patient satisfaction, delaying discharge, and increasing costs. Risk stratification uses Apfel simplified risk score: female gender, non-smoker, history of PONV or motion sickness, postoperative opioids (0-4 factors; 0 factors = 10% risk, 4 factors = 80% risk). Multimodal prophylaxis reduces PONV by 25-30% per intervention with additive effects. First-line agents: 5-HT3 antagonists (ondansetron 4 mg IV, tropisetron 5 mg IV), corticosteroids (dexamethasone 4-8 mg IV), NK1 antagonists (aprepitant 40-80 mg PO), antihistamines (cyclizine 50 mg IV/IM), anticholinergics (scopolamine patch). Total IV anaesthesia (TIVA) with propofol reduces PONV by 50% compared to volatile agents. Regional anaesthesia avoids PONV entirely by eliminating opioid requirements and volatile exposure. Rescue therapy uses different class than prophylactic agent (e.g., if ondansetron given prophylactically, use droperidol 1.25 mg IV or metoclopramide 10 mg IV for rescue). Enhanced Recovery After Surgery (ERAS) protocols incorporating multimodal anti-emetic prophylaxis achieve PONV rates <10% even in high-risk patients. Indigenous patients have higher smoking rates (reducing PONV risk) but also higher opioid use for chronic pain, requiring individualized risk stratification and multimodal approaches to minimize opioid-related PONV. [1-10]