Postoperative nausea and vomiting

Medical condition

Postoperative nausea and vomiting
Specialty	Anesthesia

Postoperative nausea and vomiting (PONV) is the phenomenon of nausea, vomiting, or retching experienced by a patient in the post-anesthesia care unit (PACU) or within 24 hours following a surgical procedure. PONV affects about 10% of the population undergoing general anaesthesia each year. PONV can be unpleasant and lead to a delay in mobilization and food, fluid, and medication intake following surgery.

Cause

Emetogenic drugs commonly used in anaesthesia include nitrous oxide, physostigmine, and opioids. The intravenous anaesthetic propofol is currently the least emetogenic general anaesthetic. These medications are thought to stimulate the chemoreceptor trigger zone. This area is on the floor of the fourth ventricle and is effectively outside of the blood-brain barrier, which makes it incredibly sensitive to toxin and pharmacological stimulation. Several neurotransmitters are known, such as histamine, dopamine, serotonin, acetylcholine, and the more recently discovered neurokinin-1 (substance P).

Risk factors

A 2008 study compared 121 Japanese patients who experienced PONV after being given the general anesthetic propofol to 790 people who were free of postoperative nausea after receiving it. Those with a G at both copies of rs1800497 were 1.6 times more likely to experience PONV within six hours of surgery compared to those with the AG or AA genotypes, but they were not significantly more likely to experience PONV more than six hours after surgery.

PONV results from patient, surgical, and anesthetic factors.

Surgical factors that confer increased risk for PONV include procedures of increased length and gynecological, abdominal, laparoscopic and ENT procedures, and strabismus procedures in children.

Anesthetic risk factors include the use of volatile anesthetics, nitrous oxide (N₂O), opioids, and longer duration of anesthesia.

Patient factors that confer increased risk for PONV include female gender, obesity, age less than 16 years, past history of motion sickness or chemotherapy-induced nausea, high levels of preoperative anxiety, and patients with history of PONV.

Smokers and the elderly often have a decreased risk for PONV.

A risk-stratification method created by Apfel et al has been developed to determine a patient's risk for PONV. The presence of 0, 1, 2, 3, or 4 of any of the following risk factors corresponds to a PONV respective risk of 10, 20, 40, 60, and 80%.

Female sex

Non-smoking

History of PONV or motion sickness

Expectant use of postoperative opioid medications

Prevention

Treatment options to prevent PONV include medications such as antiemetics (for example, ondansetron or dexamethasone) or other drugs including tropisetron, dolasetron, cyclizine, and granisetron. Droperidol may cause QT prolongation and is not frequently used. Other approaches to reduce PONV include decision on the types of anaesthetic used during surgery and intravenous (IV) dextrose solutions. Increasing the IV fluids during surgery by giving additional fluid while the person is under general anaesthesia may reduce the risk of nausea/vomiting after surgery. For minor surgical procedures, more research is needed to determine the risks and benefits of this approach.

Management

Because currently no single antiemetic available is especially effective on its own, experts recommend a multimodal approach. Anesthetic strategies to prevent vomiting include using regional anesthesia whenever possible and avoiding medications that cause vomiting. Medications to treat and prevent PONV are limited by both cost and the adverse effects. People with risk factors likely warrant preventive medication, whereas a "wait and see" strategy is appropriate for those without risk factors.

Preoperative fasting

Fasting guidelines often restrict the intake of any oral fluid 2-6 hours preoperatively, but in a large retrospective analysis in Torbay Hospital, unrestricted clear oral fluids until transfer to theatre could significantly reduce the incidence of postoperative nausea and vomiting without an increased risk in the adverse outcomes for which such conservative guidance exists.

Medications

A multimodal approach to treating a patient with PONV can be efficacious. Numerous patient factors and medication adverse effects must be taken into consideration when selecting a treatment regimen.

Serotonin (5-HT3) receptor antagonists can be administered as a single dose at the end of surgery. Adverse effects include prolongation of the QT interval on electrocardiogram (EKG). Medications include ondansetron, granisetron, and dolasetron.
Anticholinergics can be used as a long-acting patch placed behind the patient's ear. Adverse effects include dry mouth and blurry vision. Care must be taken when handling the patch, as transfer of medication to the eye can induce pupillary dilation. Avoid use in elderly patients. Medications include scopolamine.
Glucocorticoids have direct antiemetic effects and can reduce need for postoperative opioids. Adverse effects include a transient increase in serum glucose level, and poor wound healing (controversial). Medications include dexamethasone.
Butyrophenones are typically administered as a single injection at the end of surgery. Adverse effects include prolongation of the QT interval on EKG. Medications include droperidol and haloperidol.
Phenothiazines are particularly effective in treating opioid-induced PONV. Adverse effects are dose-dependent and include sedation and extrapyramidal symptoms. Medications include promethazine, chlorpromazine and prochlorperazine.
Neurokinin 1 (NK1) receptor antagonists prevent an emetic signal from being transmitted. Medications include aprepitant and rolapitant.
Histamine receptor antagonists can be administered by multiple routes, including orally, intramuscularly, or rectally. Adverse effects include dry mouth, sedation, and urinary retention. Medications include dimenhydrinate and diphenhydramine.
Propofol, an anesthetic medication, confers its own antiemetic properties.

Weibel, Rücker, Eberhart et al's 2020 Cochrane review demonstrated that combination therapy is more effective than single anti-emetic, and that dexamethasone and ondansetron (a commonly used combination) are two of the most effective anti-emetics for PONV. The review adds robust evidence of efficacy for drugs in newer classes, such as aprepitant or fosapreitant, or newer agents in familiar classes, such as ramosetron. The review does not cover the cost effectiveness of the agents included and, despite increased efficacy for newer novel agents, this may preclude their immediate utilisation in anaesthetic practice.

Alternative medicine

In conjunction with antiemetic medications, at least one study has found that application to the pericardium meridian 6 acupressure point produced a positive effect in relieving PONV. Another study found no statistically significant difference. The two general types of alternative pressure therapy are sham acupressure and the use of the P6 point. A 2015 study found no significant difference between the use of either therapy in the treatment or prevention of PONV. In a review of 59 studies, both therapies significantly affected the nausea aspect, but had no significant effect on vomiting.

Cannabinoids have also been used for treatment of PONV, but its safety and efficacy are controversial.

Epidemiology

Typically, the incidence of nausea or vomiting after general anesthesia ranges between 25 and 30%. Nausea and vomiting can be extremely distressing for patients, and so is one of their major concerns. Vomiting has been associated with major complications, such as pulmonary aspiration of gastric content, and might endanger surgical outcomes after certain procedures, for example after maxillofacial surgery with wired jaws. Nausea and vomiting can delay discharge, and about 1% of patients scheduled for day surgery require unanticipated overnight admission because of uncontrolled PONV.

References

^ Jewer, James K; Wong, Michael J; Bird, Sally J; Habib, Ashraf S; Parker, Robin; George, Ronald B (29 March 2019). "Supplemental perioperative intravenous crystalloids for postoperative nausea and vomiting". Cochrane Database of Systematic Reviews. 2019 (4): CD012212. doi:10.1002/14651858.CD012212.pub2. PMC 6440702. PMID 30925195. S2CID 80300081.
Nakagawa, Masashi; Kuri, Michioki; Kambara, Noriko; Tanigami, Hironobu; Tanaka, Hideo; Kishi, Yoshihiko; Hamajima, Nobuyuki (February 26, 2008). "Dopamine D2 receptor Taq IA polymorphism is associated with postoperative nausea and vomiting". Journal of Anesthesia. 22 (4): 397–403. doi:10.1007/s00540-008-0661-z. PMID 19011779. S2CID 19342889 – via PubMed.
Apfel, Christian C.; Läärä, Esa; Koivuranta, Merja; Greim, Clemens-A.; Roewer, Norbert (September 1999). "A Simplified Risk Score for Predicting Postoperative Nausea and Vomiting". Anesthesiology. 91 (3): 693–700. doi:10.1097/00000542-199909000-00022. PMID 10485781.
McCracken, Graham C.; Montgomery, Jane (May 2018). "Postoperative nausea and vomiting after unrestricted clear fluids before day surgery: A retrospective analysis". European Journal of Anaesthesiology. 35 (5): 337–342. doi:10.1097/EJA.0000000000000760. PMID 29232253. S2CID 4486702.
Gibbison, Ben; Spencer, Ruth (December 2009). "Post-operative nausea and vomiting". Anaesthesia & Intensive Care Medicine. 10 (12): 583–585. doi:10.1016/j.mpaic.2009.09.006.
Weibel, Stephanie; Rücker, Gerta; Eberhart, Leopold HJ; Pace, Nathan L; Hartl, Hannah M; Jordan, Olivia L; Mayer, Debora; Riemer, Manuel; Schaefer, Maximilian S; Raj, Diana; Backhaus, Insa; Helf, Antonia; Schlesinger, Tobias; Kienbaum, Peter; Kranke, Peter (19 October 2020). "Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis". Cochrane Database of Systematic Reviews. 2020 (11): CD012859. doi:10.1002/14651858.CD012859.pub2. PMC 8094506. PMID 33075160.
Fan, Chin-Fu; Tanhui, Eduardo; Joshi, Sanjoy; Trivedi, Shivang; Hong, Yiyan; Shevde, Ketan (April 1997). "Acupressure Treatment for Prevention of Postoperative Nausea and Vomiting". Anesthesia & Analgesia. 84 (4): 821–825. doi:10.1213/00000539-199704000-00023. PMID 9085965.
Samad, K; Afshan, G.; Kamal, R. (February 2003). "Effect of acupressure on postoperative nausea and vomiting in laparoscopic cholecystectomy". Journal of Pakistan Medical Association. 53 (2): 68–72. PMID 12705488.
Wongyingsinn, Mingkwan; Peanpanich, Pechprapa; Charoensawan, Sirirat (21 October 2022). "A randomized controlled trial comparing incidences of postoperative nausea and vomiting after laparoscopic cholecystectomy for preoperative intravenous fluid loading, ondansetron, and control groups in a regional hospital setting in a developing country". Medicine. 101 (42): e31155. doi:10.1097/MD.0000000000031155. PMC 9592396. PMID 36281094.
Eberhart, L. H. J.; Morin, A. M.; Wulf, H.; Geldner, G. (November 2002). "Patient preferences for immediate postoperative recovery". British Journal of Anaesthesia. 89 (5): 760–761. doi:10.1093/bja/89.5.760. PMID 12393775.

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Classification	D MeSH: D020250

v t e Anesthesia and anesthesiology
Types	General Sedation Procedural sedation and analgesia Twilight anesthesia Local Continuous wound infiltration Topical Neuraxial blockade Combined spinal and epidural anaesthesia Epidural anesthesia Spinal anaesthesia Nerve block Brachial plexus block Fascia iliaca block Femoral nerve block Inferior alveolar nerve block Intercostal nerve block Interpleural block Intravenous regional anesthesia Occipital nerve block Paracervical block Pudendal nerve block Retrobulbar block Sciatic nerve block Transverse abdominis plane block Total intravenous anaesthesia
Pharmacologic agents	Anticholinergics Antiemetics Butyrophenones Benzodiazepines General anesthetics Inhalational anesthetics Local anesthetics Neuromuscular-blocking drugs Opioids Sedatives
Techniques	Airway management Anesthesia provision in the US Bronchoscopy Dogliotti's principle Intravenous therapy Laryngoscopy Tracheal intubation Rapid sequence induction
Scientific principles	Blood–gas partition coefficient Concentration effect Fink effect Minimum alveolar concentration Second gas effect
Measurements	ASA physical status classification system Baricity Bispectral index Body mass index Capnography Entropy monitoring Fick principle Goldman index Guedel's classification Intraoperative neurophysiological monitoring Mallampati score Neuromuscular monitoring Pain scale Thyromental distance
Instruments	Anaesthetic machine Anesthetic vaporizer Arterial catheter Bronchial blocker Double-lumen endobronchial tube Gas cylinder Laryngeal mask airway Laryngeal tube Magill forceps Relative analgesia machine Tracheal tube
Complications	Allergic reactions Anesthesia awareness Drug-induced amnesia Effects of early-life exposures to anesthesia on the brain Emergence delirium Local anesthetic toxicity Malignant hyperthermia Perioperative mortality Postanesthetic shivering Postoperative nausea and vomiting Postoperative residual curarization
Subspecialties	Cardiothoracic Critical emergency medicine Geriatric Intensive care medicine Obstetric Oral sedation dentistry Pain medicine
Professions	Anesthesiologist Anesthesiologist assistant Nurse anesthetist Operating department practitioners Certified anesthesia technician Certified anesthesia technologist Anaesthetic technician Physicians' assistant (anaesthesia)
History	ACE mixture Helsinki Declaration for Patient Safety in Anaesthesiology History of general anesthesia History of neuraxial anesthesia History of tracheal intubation
Organizations	American Association of Nurse Anesthetists American Society of Anesthesia Technologists & Technicians American Society of Anesthesiologists Anaesthesia Trauma and Critical Care Association of Anaesthetists of Great Britain and Ireland Royal College of Anaesthetists Association of Veterinary Anaesthetists Australian and New Zealand College of Anaesthetists Australian Society of Anaesthetists International Anesthesia Research Society European Society of Anaesthesiology and Intensive Care
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