Pharmacological prophylaxis and management of adult postoperative/postdischarge nausea and vomiting

Abstract

Postoperative nausea and vomiting (PONV) is a relatively common complication that can adversely affect the quality of a patient's postoperative recovery. Factors to consider when determining a patient's risk for developing PONV include female gender, history of PONV, history of motion sickness, nonsmoking status, postoperative use of opioids, use of inhaled anesthetic agents, and use of nitrous oxide. Receptors that, when activated, can cause PONV include dopamine type-2, serotonin type-3, histamine type-1, muscarinic cholinergic type-1, and neurokinin type-1. Patients with a moderate-to-high risk of developing PONV will benefit from the administration of a prophylactic antiemetic agent that blocks one or more of these receptors. Effective agents for prophylaxis include transdermal scopolamine, prochlorperazine, promethazine, droperidol, ondansetron, dolasetron, granisetron, dexamethasone, and aprepitant. In the highest-risk patients, combining two or more prophylactic antiemetics with different mechanisms of action has been shown to be more effective than a single agent. In addition, the patient's risk could be reduced by considering the use of regional anesthesia, maintaining general anesthesia with propofol rather than with inhaled anesthetic agents, ensuring good intravenous hydration, and providing effective pain management using a multimodal approach (eg, minimizing the use of opioids). If PONV does occur in the immediate postoperative period, it is best treated with an antiemetic agent from a different pharmacologic class than the agent that was administered for prophylaxis. Once a patient is discharged, alternative formulations of antiemetics such as ondansetron oral or dissolving tablets or promethazine tablets or suppositories can be used.