Prophylaxis and treatment of postoperative nausea and vomiting

By reading this article, you should be able to: State the incidence of postoperative nausea and vomiting (PONV), postdischarge nausea and vomiting (PDNV) in adults and postoperative vomiting (POV) in children. Describe management strategies to reduce the risk of PONV, PDNV and POV. List the different medications available for the prevention and treatment of PONV. Describe current management strategies using combination and multimodal antiemetic therapy for the prophylaxis and treatment of PONV.Despite the implementation of multimodal pain management strategies and enhanced recovery after surgery (ERAS) protocols, postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) continue to be distressing problems and remain a challenge.After elective surgery, without prophylaxis, the overall incidence of PONV is 20-30%, and up to 70% in high-risk patients. 1A systematic review by Eberhart and colleagues reported a high rate of recurrence of emetic symptoms after a first episode in the recovery room after placebo or no treatment, suggesting the need for subsequent antiemetic treatment. 2For PONV (any symptoms of nausea or emesis), the recurrence rate was 65-84%, and for vomiting, 65-78%.Apfel and colleagues determined that PDNV may occur with a combined nausea and vomiting incidence of about 37% and persist up to 4-5 days after surgery. 3After the age of 3 yrs, PONV increases in children with a peak incidence of about 40% in the 11-to 14yr-old age group.Before puberty, there were no apparent differences in PONV incidence between boys and girls. 4ithout intervention, PONV and PDNV can lead to dissatisfaction, prolonged stay in the PACU and delayed discharge after ambulatory surgery.Adverse events associated with PONV can also cause unexpected hospital admissions, thereby increasing healthcare costs. 5The occurrence of PONV and PDNV can depend on the location of the health facility and whether interventions were used to reduce PONV or PDNV. 6ONV prevention can be achieved with risk assessment, baseline risk reduction and antiemetic prophylaxis.Patient, anaesthesia and surgery-related risk factors should be