Guideline sources The following summarized guidelines for the evaluation and management of postoperative nausea and vomiting (PONV) are prepared by our editorial team based on guidelines from the Global Alliance for Infection in Surgery (GAIS/WSES/AAST/SIAARTI 2022), the Society for Ambulatory Anesthesia (SAMBA/ASER 2020), the British Thoracic Society (BTS 2017), and the Society of Obstetricians and Gynaecologists of Canada (SOGC 2008). 1 2 3 4 Calculator Apfel score for postoperative na Guidelines 1. Classification and risk stratification Risk assessment: Assess the following to identify the patient's risk for PONV: female gender B younger age B nonsmoking status B history of PONV B hi t f ti i k https://web.pathway.md/diseases/recdk1qK5g62CNygw 1/5 6/29/23, 11:22 PM Postoperative nausea and vomiting Pathway history of motion sickness B general versus regional anesthesia A use of volatile anesthetics and nitrous oxide A use of postoperative opioids A duration of anesthesia B type of surgery, such as laparoscopic, bariatric, gynecological surgery, and cholecystectomy. B Recognize that the following factors have conflicting, disproven, or limited clinical relevance: ASA physical status B menstrual cycle B level of anesthesia provider's experience B perioperative fasting A BMI B anxiety B nasogastric tube A migraine B supplemental oxygen. A 2. Medical management Management of PONV: As per WSES 2022 guidelines: Administer medications targeting dopaminergic pathways (such as haloperidol, risperidone, metoclopramide, and prochlorperazine) for the management of PONV. B Consider adding a second agent (such as ondansetron) for the management of PONV when first-line medications fail to control the symptoms. B As per ASER 2020 guidelines: Ensure timely management of PONV. E Administer antiemetics in patients with PONV not received prophylaxis or in case of prophylaxis failure. E As per SOGC 2008 guidelines, administer antiemetic treatment as soon as feasible in patients with PONV not received prophylaxis or if prophylaxis failed. Do not administer a repeat dose of the same drug as rescue therapy when prophylaxis with that drug has failed. Administer a drug from a different class of antiemetic drugs. B Show 2 more 3. Preventative measures Risk reduction: As per ASER 2020 guidelines, implement the following strategies to reduce the baseline risk for PONV: https://web.pathway.md/diseases/recdk1qK5g62CNygw 2/5 6/29/23, 11:22 PM Postoperative nausea and vomiting Pathway use regional anesthesia to avoid general anesthesia A use propofol for induction and maintenance of anesthesia A avoid using nitrous oxide in surgeries lasting > 1 hour A avoid using volatile anesthetics A minimize intraoperative A and postoperative opioids A provide adequate hydration A use sugammadex instead of neostigmine for the reversal of neuromuscular blockade. A As per SOGC 2008 guidelines, reduce the baseline risks of PONV whenever possible. B Show 2 more Prevention of PONV, indications: As per SAMBA/ASER 2020 guidelines, implement general multimodal PONV prevention. Administer multimodal prophylactic antiemetics in enhanced recovery pathways. E Show 2 more As per SOGC 2008 guidelines: Administer prophylactic antiemetics in patients with a moderate or high risk of developing PONV. B Consider administering combination antiemetic therapy in patients with a high risk of developing PONV. C Prevention of PONV (choice of agent): Administer prophylactic antiemetics in adult patients from the following options, including the corresponding doses and timing: Situation Guidance 5 mg, A at induction A Amisulpride 40 mg PO, A at induction A Aprepitant 150 mg PO, A at induction Casopitant 4-8 mg IV, A at induction A Dexamethasone 1 mg/kg IV A Dimenhydrinate 12.5 mg IV, A end of surgery A Dolasetron 0.625 mg IV, A end of surgery A Droperidola 0.5 mg/kg IM A Ephedrine 0.35-3 mg IV, A end of surgery A Granisetron 0.5 to < 2 mg IM/IV A Haloperidol 40 mg IV A Methylprednisolone 10 mg A Metoclopramide 4 mg IV or 8 mg PO or PO disintegrated tablet, A end of surgery A Ondansetron https://web.pathway.md/diseases/recdk1qK5g62CNygw 3/5 6/29/23, 11:22 PM Postoperative nausea and vomiting Pathway Palonosetron 0.075 mg IV A 5 mg IV A Perphenazine 6.25 mg A Promethazinea 0.3 mg IV, A end of surgery A Ramosetron 70-200 mg PO, A at induction Rolapitant Transdermal patch, A prior evening or 2 hours before surgery A Scopolamine 2 mg IV, A end of surgery A Tropisetron Show 3 more Prevention of PONV, acupoint stimulation: As per SAMBA/ASER 2020 guidelines, consider performing acupoint stimulation in combination with pharmacoprophylaxis in adult patients at risk for PONV. B As per SOGC 2008 guidelines, consider performing acupoint electrical stimulation as an alternative or adjuvant therapy for the prevention of PONV. B Prevention of PONV (oxygen supplementation): do not induce hyperoxemia routinely in the perioperative and postoperative period to reduce the incidence of PONV. D Clinical findings Symptoms Past medical history Nausea Diabetes mellitus Vomiting Hypothyroidism Motion sickness Medication history Past obstetric history Exposure to inhalation anesthetics Pregnancy Exposure to nitrous oxide Opioids Past surgical history Bariatric surgery Cholecystectomy General anesthesia Gynecological surgery Recent surgery References https://web.pathway.md/diseases/recdk1qK5g62CNygw 4/5 6/29/23, 11:22 PM Postoperative nausea and vomiting Pathway 1. O'Driscoll BR, Howard LS, Earis J et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72 Suppl 1):ii1-ii90. Open 2. Tong J Gan, Kumar G Belani, Sergio Bergese et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020 Aug;131 2 411 448. Open 3. Geoff McCracken, Patricia Houston, Guylaine Lefebvre et al. Guideline for the management of postoperative nausea and vomiting. J Obstet Gynaecol Can. 2008 Jul;30 7 600 7, 608 16. Open 4. Federico Coccolini, Francesco Corradi, Massimo Sartelli et al. Postoperative pain management in non-traumatic emergency general surgery: WSES GAIS SIAARTI AAST guidelines. World J Emerg Surg. 2022 Sep 21;17 1 50. Open 5. Apfelbaum JL, Silverstein JH, Chung FF et al. Practice guidelines for postanesthetic care: an updated report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology. 2013 Feb;118 2 291 307. Open 6. Bell GC, Caudle KE, Whirl-Carrillo M et al. Clinical Pharmacogenetics Implementation Consortium CPIC guideline for CYP2D6 genotype and use of ondansetron and tropisetron. Clin Pharmacol Ther. 2017 Aug;102 2 213 218. Open 7. DREAMS Trial Collaborators and West Midlands Research Collaborative. Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial DREAMS Trial). BMJ. 2017 Apr 18;357:j1455. Open 8. Y H Wu, H S Sun, S T Wang et al. Applicability of risk scores for postoperative nausea and vomiting in a Taiwanese population undergoing general anaesthesia. Anaesth Intensive Care. 2015 Jul;43 4 473 8. Open 9. C C Apfel, E L r , M Koivuranta et al. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology. 1999 Sep;91 3 693 700. Open https://web.pathway.md/diseases/recdk1qK5g62CNygw 5/5