Post- Operative nausea and Vomiting (PONV)
Apfel et al. A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting. NEJM 2004; 350: 244151
Gan TJ, et al. Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea
and Vomiting. Anes Analg 2007;105:1618-28.
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Untreated, 1/3 will have post op n, v or both. In high risk estimated as high as 70-80%
Annual costs in the US is estimated to be around several hundred million dollars
Physiology of Vomiting--main sensors of somatic stimuli are located in the gut and chemo-receptor trigger zone (CTZ)
--triggered by stimulation of chemo receptors in the upper GI tract and mechanoreceptors in the
wall of the GI tract
--area postrema is rich in dopamine-r and is a target for antagonists: haloperidol, metoclopramide,
and the phenothiazines
--Histamine-1 and muscarinic cholinergic recepotors are present in the nucleus ambiguous and
lateral vestublar nucleus
--5-hydroxytryptamine (5HT)-receptors are also present w/i the area postrema.5HT can activate
dopamine release
Causes:
1. Pharyngeal stimulation
2. Gastrointestingal distension
3. Abdominal Surgery
4. Anesthetic agents
5. Pain
6. Opiod medications
7. Hypoxia
8. HTN
9. Vestibular disturbances
10. Psychological factors
11. MI
12. Appendicitius, cholecystitis, pancreatitis, SBO, elevated ICP,
Factors to consider that may predispose patients to a higher incidence:
1. Patient factors
a. Female gender
b. Non-smoker
c. h/o motion sickness or h/o ponv
d. Environmental: use of postop opioids, emetogenic surgery (type + duration)
e. Obesity- believed to 2/2 excessive production of estrogen from adipose tissue
and excessive stores of anesthetic agents w/I adipose.
f. Conditions that predispose to delayed gastric emptying: DM, hypothyroidism,
pregnancy, or other intrabdominal pathology.
g. Type of surgery (i.e. gyn, abdominal, ophthalmologic, lap)
Pharmacological treatment options: (see next page Table)
Summary:
--Pt’s at high risk of PONV should receive prophylaxis with a combo therapy. --when PONV
occurs post-op, treatment should be admistered with an antiemetic from a different drug class
from that given introp.
Drug treatment of nausea and vomiting
Drug Class
Generic Name
(Trade Name)
Uses
Recommended
Doses
Side Effects
Phenothiazines
Chlorpromazine
(Thorazine)
Uncommonly used
for Nausea and
Vomiting
10 - 25 mg q 4 - 6 po
25mg q 3h IV slow
25-50 mg q 4h IM
100 mg q 6-8h pr
Hypotension
Prochlorperazine
(Compazine)
Nausea and vomiting
5-10 mg tid po
2.5 10 mg IV slow infusion
5-10 mg q 4h IM
25 mg bid pr
Hypotension
Metoclopramide
(Reglan)
Gastroparesis
10-20 mg qid po
10-20 mg IV
Extrapyramidal
symptoms
Cisapride
(Propulsid)
GERD
10-20 mg qid po
Abd pain, diarrhea
Drowsiness
Trimethobenzamide
(Tigan)
Nausea and
vomiting
250 mg tid/qid po
200 mg tid/qid IM
200 mg tid/qid pr
Diarrhea, abd pain
Erythromycin
Gastroparesis
250 mg qid IV or po
Abd pain
Bethanechol
Gastroparesis
10-25 mg qid po
Abd pain
Dymenhydrinate
(Dramamine)
Motion sickness
50 mg q 4h po
Drowsiness
Meclizine
(Antivert)
Motion sickness
50 mg q 24h po
Drowsiness
Cyclizine
(Marezine)
Meniere's disease
50 mg q 4h po
50 mg q 4h IV
Drowsiness
Promethazine
(Phernagen)
Motion Sickness
25 mg q 12h po
25 mg q 12h IV
12.5-50 mg q 12h IM
12.5-50 mg q 12h pr
Drowsiness
Dyphenhydramine
(Benadryl)
Motion Sickness
25-50 mg q 6h po
Drowsiness
Droperidol
Post-op
2.5-5 mg IV
Hypotension
Sedation
Extrapyramidal
symptoms
Haloperidol
Rarely used
0.5-2 mg po
Hypotension
Sedation
Extrapyramidal
symptoms
Anticholinergics
Scopolomine
(Transderm patch)
Motion Sickness
1.5 mg patch q 3 days
delivers 0.5g/day
Drowsiness
5-HT3 Receptor
Antagonists
Ondansetron
(Zofran)
Post-op
Chemotherapy
4 - 8 mg IV
32 mg one time dose
Elevated LFTs
Granisetron
(Kytril)
Chemotherapy
1 mg bid po
10 mcg/kg IV
Headache
Prokinetics
Antihistamines
Butyrophenones