PONV Guidelines

Guidelines Summarised by Ms Lee Sz-Ying & Mr John Tsao, Yong Loo Lin School of Medicine, NUS

Post operative nausea and vomiting can be highly distressing to patients, with reported incidences of up to 30% in the general surgical population, and up to 80% in high risk populations. The following is a summary of the Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. 

Further Reading: TJ Gan et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anaesthesia & Analgesia August 2020.

The article presents the fourth consensus guidelines for the management of postoperative nausea and vomiting (PONV) developed based on a comprehensive review of recent literature updated to September 2019 and endorsed by multiple professional bodies worldwide. The following recommendations were highlighted:

1. Risk assessment

The significance of identified risk factors for PONV in adults are categorically stratified based on the quality of clinical evidence that can be used to guide treatment prophylaxis. The use of scoring namely Apfel scores (a separate scoring is included for post-discharge nausea and vomiting (PDNV)) can be especially useful to objectively stratify risks needed in cases where vomiting poses a medical risk. A similar illustration of predictive risk factors and scoring by Eberhart has also been applied to the pediatric population. For the paediatric population, POVOC (postoperative Vomiting in Children) score is recommended.

2. Baseline risk reduction

Several strategies have been proposed to counteract modifiable risks involved which generally include the avoidance of general anesthesia especially volatile anesthetics and prolonged use of nitrous oxide (in surgeries longer than 1 hour) with a proponent for TIVA propofol or alternatively regional anesthesia as appropriate. Recommendations for opioid-sparing analgesic therapies as well as the use of sugammadex over neostigmine in paralytic reversal have also been called upon. Supportively, adequate hydration should be maintained.

Unfortunately, more studies are also required in deconflicting the choice, volume, and timing of fluid administration.

3. Multimodal prophylaxis

A detailed table of dosing, timing and combination therapies have been outlined (a separate algorithm and table for dosing antiemetics in children can also be found in the article differing from adults). The updated guidelines recommend the use of multimodal prophylaxis in patients with any risk factors as the default. Provision of additional agents of treatment is tailored according to the quantified number of risk factors.

There are still uncertainties in the choice, the optimal combination prophylaxis regimen and added value of acupoint stimulation as a modality which will require greater clarification in future research. The article advises clinical judgement.

 

Image: TJ Gan et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anaesthesia & Analgesia August 2020.

4. Rescue regimens

First line treatment in patients without initial PONV prophylaxis are 5-HT3 receptor antagonists with other options and combination therapies discussed notably NK1 receptor antagonist. Failure of treatment warrants a change in pharmalogical class of antiemetic treatment especially within 6 hours. A repeat dose of short-acting antiemetic may be considered if no alternatives can be implemented after 6 hours of last administration. Reversible causes of PONV should also be evaluated for.

Image: TJ Gan et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anaesthesia & Analgesia August 2020.

5. Improvements in clinical effectiveness

Emphasis have been placed on increasing compliance, application, and timely intervention to said recommended protocols in clinical setting to maximize utility. To minimize unintended consequences, patient and surgical factors should be examined not withstanding patient preferences, medical history, and costs in the selection of treatment as well as following lowest recommended doses.

Emerging evidence on genetic influences from polymorphisms and expression contributing to antiemetic efficacy demands better understanding of their associations.

6. Applications in Enhanced Recovery Pathways (ERPs)

General review of published specific PONV management in various types of surgical ERPs concludes the applicability of current guidelines in principle to ERPs.

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