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The Treatment of Postoperative
Nausea and Vomiting
1
Nausea
• by Jean-Paul Sartre
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Muscular contractions associated
with nausea and vomiting
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Chemoreceptor Trigger Center
(CTZ)
•“Antiemetics” , J Scholz, MD, PhD, M Steinfath, MD, PhD, PT Tonner,
MD, Phd p777 – 791; in Anesthetic Pharmacology, AS Evers and M
Maze, 2004
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Anatomy and physiology of the vomiting centre and
the chemoreceptor trigger zone
World Federation of Societies of Anaesthesiologists
WWW implementation by the NDA Web Team, Oxford
Issue 17 (2003) Article 2: Page 1 of 1
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5HT-Receptor and PONV
Pathophysiology
•“Antiemetics” , J Scholz, MD, PhD, M Steinfath, MD, PhD, PT Tonner, MD, Phd p777 – 791; in Anesthetic
Pharmacology, AS Evers and M Maze, 2004
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Chemoreceptor Trigger Zone
and Emetic Center
Antagonist
5-HT3 RAs
Promethazine
5-HT3
Histamine
Atropine
Droperidol
NK-1 RA
Agonist
Area
Postrema
Receptor Site
Chemoreceptor
Trigger
Zone
(CTZ)
Muscarinic Dopamine (D2) Substance P
Nitrogen mustard
Cisplatin
Digoxin glycoside
Opioid, analgesics
Vestibular portion
of 8th nerve
Mediastinum
Parvicellular
Reticular
Formation
Emetic
Center
N2O
?
Watcha MF, White PF. Anesthesiology. 1992;77:162–184.
GI tract distension
Higher centers (vision, taste)
Pharynx
Post Operative Nausea & Vomiting:
The Role of Antiemetics - Cedric Dupont-Eisner M.D.
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Schematic representation of the factors
influencing nausea and vomiting
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www.marinol.com/images/graphic-cancer.gif
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A final pathway for nausea
http://www.mywhatever.com/cifwriter/library/70/4938.html
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PONV Impact
• Incidence of PONV: varies with age, surgical procedure,
anesthetic technique
• Emesis frequently occurs after D/C from PACU = incidence
lower in PACU than over 24 – 48 h
• Delayed emesis: timing of oral intake or waning effects of
perioperative antiemetics
• Vomiting - unpleasant and medical risks: aspiration of gastric
content; jeopardizes abdominal or inguinal closures; increased IV
pressure: increase morbidity after ocular, tympanic, intracranial
procedures; elevate HR and BP: risk for MI and dysrhythmias;
gagging and retching: parasympathetic response: bradycardia and
hypotension.
13
Demographic Factors for PONV
• Study of 17,638 ambulatory patients: increased risk in younger
pts.: PONV decreasing 13% per decade of age. (“Anesthesiology”
– 1999;91:109, Sinclair DR, Chung F, Mezei G)
• Women: 3 times higher incidence than men
• Increased with GA and duration of GA
• ENT and dental had higher incidence (14.3%), followed by
orthopedic shoulder and plastic
• Hx. of preop. emesis or motion sickness
• GA near menses (increase E2)
• High: procedures of extraocular muscles or middle ear,
peritoneal or intestinal irritation, testicular traction
• Smokers: lower risk
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Contributing Factors
• Risk of PONV: increased by
starvation, gastric irritation,
effects of anesthetics on
chemotactic centers, autonomic
imbalance, postoperative pain
• Swallowed blood or tissue, gas in
the stomach
• General Anesthesia more than
regional, although vomiting
frequently when parenteral
narcotics.
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Major causes of nausea and vomiting
Drug/treatment - induced
Cancer chemotherapy
Opiates
Nicotine
Antibiotics
Radiotherapy
Labyrinth disorders
Motion
Meniere's disease
Endocrine causes
Pregnancy
Infectious causes
Gastroenteritis
Viral labyrinthitis
Increased intracranial pressure
Haemorrhage
Meningitis
Post-operative
Anaesthetics
Analgesics
Procedural
CNS causes
Anticipatory
Migraine
Bulimia nervosa
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Major Risk Factors for PONV in Adults
•
•
•
Patient-specific Risk Factors
- Age (adult)
- Non-smoking status
- History of PONV / motion sickness
- Predisposing gastric disorders
- Low threshold for nausea
- Preoperative anxiety
- Obesity (disputed in recent studies)
- Gastric distension (disputed in recent studies)
Anesthetic Risk Factors
- Pre-anesthetic medications (opioids, atropine)
- Volatile anesthetics
- Nitrous Oxide
- Intraoperative or postoperative use of opioids
- Duration of anesthesia (> 120 min)
Surgical Risk Factors
- Duration of surgery (each 30 min increases PONV risk by 60%)
- Type of surgery (craniotomy; ear, nose, throat procedures; major breast procedures;
strabismus surgery; laparoscopy; laparotomy).
- Intubation (disputed in recent studies)
- Early oral intake
Am J Health Syst Pharm 1999;56:729-764
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Specific factors increasing risk of nausea
and vomiting - PONV
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•
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•
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•
•
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•
•
adults have more PONV than children
women
obesity
delayed gastric emptying disorders (GERD, GI obstruction, & neuromuscular
disorders)
history of motion sickness (which can cause movement-induced PONV when
patient is moved or turned) and/or history of PONV
history of smoking decreases risk
anxious person
emotogenic factors of anaesthetic
etomidate (Amidate), ketamine, and gaseous general anaesthesia, including
nitrous oxide have higher risk
atropine decreases risk because it is a vagolytic
propofol (Diprivan) also decreases risk, probably because has slightly antiserotonergic properties; but, is indicated only as a sedative-hypnotic; it has antiemetic properties, but is not currently indicated solely for that use
longer procedures with general anaesthesia
Garrett, K., Tsuruta, K., Walker, S., Jackson, S., & Sweat, M. (2003)
http://www.eddyelmer.com/tools/aemetic.htm
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Risk Score for Predicting PONV
RISK FACTORS:
1 -Female sex
2 - Hx. of motion
sickness or PONV
3 - Nonsmoking status
4 - Use of Postoperative
Opioids
NONE
1 Factor
2 Factors
3 Factors
4 Factors
10 %
21 %
39 %
61 %
79 %
Apfel CC et al – “A simplified risk score for predicting postoperative nausea and vomiting” – Anesth;
91:693-700, 1999.
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Anesthetic Agents
• Exclusion of Nitrous Oxide reduces the incidence of PONV
• PONV not different among potent inhalation anesthetics: except
sevoflurane (marginally higher incidence)
• Barbiturate induction less offensive than ketamine or
etomidate; propofol induction lowest incidence
• Narcotic analgesics: increase PONV
• Ketorolac with small doses of narcotics: reduce severity of
PONV
• Neostigmine, physostigmine: increase the incidence of PONV
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PONV Prevention and Treatment
• Adequate postop. analgesia
• Limit postoperative vestibular stimulation
(minimize brisk head movement)
• Avoid gastric distension (OG tube?)
• Adequate hydration (Anesth Analg 1995;80:682;
Yogendran S, Kumar B, Cheng D), but initiation
of postop drinking is frequently a triggering event
• Sometimes D/C children or high-risk patients
before they take oral fluids
• Nausea and Vomiting: also signs of serious
underlying physiologic abnormalities – evaluate
hypotension, increased ICP, hypoxemia,
hypoglycemia, gastric bleeding.
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Strategies to Reduce Baseline Risk
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•
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Use Regional Anesthesia
Use of Propofol for induction and maintenance
Use of intraoperative supplemental oxygen
Hydration
Avoid Nitrous Oxide and Volatile Anesthetics
Minimize intraoperative and postoperative
opioids
• Minimize the use of Neostigmine
Anesth Analg 2004; 99;77-81.
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“Management of PONV’ – Habib et al / CAN J ANESTH; 2004; 51:4; pp 326 - 341
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Effect of intraoperative intravenous
crystalloid infusion on PONV
• IV administration of CSL 30 ml/kg to healthy
women undergoing day-case gynecological
laparoscopy reduced the incidence of vomiting,
nausea and anti-emetic use when compared with
CSL 10 ml/kg.
Br J Anaesth. 2004 Sep;93(3):381-5. Epub 2004 Jun 25
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Antiemetics—Members by Class
Phenothiazines
– Chlorpromazine,
prochlorperazine,
promethazine
Butyrophenones
Antihistamines
– Dimenhydrinate,
hydroxyzine, cyclizine
5-HT3 antagonists
– Dolasetron, granisetron,
ondansetron
– Droperidol (haloperidol)
Benzamides
– Metoclopramide
Others
Anticholinergics
– Scopolamine
Upcoming class for PONV already
approved for CINV
NK1-receptor antagonists
– Dexamethasone
– Dronabinol (9THC)
Post Operative Nausea & Vomiting:
The Role of Antiemetics - Cedric
Dupont-Eisner M.D.
26
•“Antiemetics” , J Scholz, MD, PhD, M Steinfath, MD,
PhD, PT Tonner, MD, Phd p777 – 791; in Anesthetic
Pharmacology, AS Evers and M Maze, 2004
27
Main classes of anti-emetic drugs
Class
Drug
Anti-cholinergic
scopolamine (L-hyoscine)
Anti-histamine
cinnarizine
cyclizine
promethazine (?)
Dopamine antagonists
metoclopramide
domperidone
droperidol (withdrawn 2001)
haloperidol
Cannabinoid
nabilone
Corticosteroid
dexamethasone
Histamine analogue
betahistine
5HT3-receptor antagonist
granisetron
ondansetron
tropisetron
Source: British National Formulary, March 2002
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Agonists and Antagonists Associated
with Nausea and Vomiting
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Clinical Aspects in Selecting
Antiemetics for Prevention of PONV
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“Management of PONV’ – Habib et al / CAN J ANESTH; 2004; 51:4; pp 326 - 341
33
Antiemetic treatment for PONV Patients
with No Prophylaxis or Failed
Prophylaxis
If Initial Tx. Was:
Then Treat With:
No prophylaxis or dexamethasone.
Low-dose 5-HT3-receptor antagonist
(Ondansetron 1 mg, Dolasetron 12.5 mg,
Granisetron 0.1 mg, Tropisetron 0.5 mg).
5-HT3-receptor antagonist plus 2nd
agent (droperidol 0.625 mg IV, dexamethasone
2 – 4 mg IV, promethazine 12.5 mg IV).
Triple therapy with 5-HT3-receptor
antagonist plus 2 other agents.
Agent from a different class.
When PONV occurs <6h after surgery: use
agent from different class or Propofol 20 mg
in PACU (adults).
When PONV occurs >6h after surgery:
repeat 5-HT3-receptor antagonist and
droperidol (except dexamethasone or
scopolamine)
Use agents from a different class.
Anesth Analg 2003;97:62-71
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Standard Dosages of Antiemetics for the
Prophylaxis of PONV in Adults
Am J Health Syst Pharm 1999;56:729-764
Agent
Dosage
Droperidol
0.625 – 1.25 mg Iv 5 min before termination of
anesthesia
Ondansetron
4 mg IV immediately before induction
8 mg PO 1 h before induction
Recent data: more effective- end of anesthesia
Dolasetron
12.5 mg IV intraoperatively
100 mg PO 1 h before induction
Metoclopramide
10 (20) mg IV near the end (not effective when
used alone)
Promethazine
25 mg PO 1 h before induction
12.5 – 25 mg IV immediately before ind.
Prochlorperazine
5 – 15 mg PO 1 h before induction
5 – 10 mg IM 1 – 2 h before ind.; repeat once in
30 min, prn
5 – 10 mg IV 15 – 30 min before ind; x1
Granisetron
20 – 40 mcg/kg IV
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Standard Dosages of Antiemetics for
the Treatment of PONV in Adults
Am J Health Syst Pharm 1999;56:729-764
Agent
Dosage
Ondansetron
1 – 4 mg IV postoperatively
Metoclopramide
10 mg IV q 4–6 h prn post-operatively
Promethazine
10 – 25 mg PO prn post-operatively
12.5 – 25 mg IM or IV q4h prn post-operatively
Prochlorperazine
5 – 15 mg PO post-op.
5 – 10 mg IM; repeat once in 30 min prn
5 – 10 mg IV; may repeat once prn
Chlorpromazine
10 – 25 mg PO q4-6h prn
12.5 – 25 mg IM if no hypotension; repeat in 1h
Droperidol
0.625 – 1.25 mg IV prn
Dolasetron
12.5 mg IV post-operatively
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Standard Dosages of Antiemetics for
the Management of POV in Pediatric
Patients
Agent
Prophylaxis
Dosage
Dolasetron
Age >2y: 1.8 mg/kg IV immediately before ind.
Ondansetron
0.05 mg/kg IV (range: 0.05 – 0.15 mg/kg)
Droperidol
0.015 – 0.075 mg/kg per dose IV
Treatment
Chlorpromazine
0.55 mg/kg PO or IM
Droperidol
0.1 mg/kg per dose IV
Ondansetron
0.05 mg/kg per dose IV
Am J Health Syst Pharm 1999;56:729-764
37
Phenothiazines
• Chlorpromazine,
Prochlorperazine, Promethazine
– Antipsychotic agents
– Blocks D2 receptors in
CTZ and CNS
– SIDE EFFECTS: EPS,
sedation, dizziness, blurred
vision, skin reactions,
orthostatic hypotension
Prochlorperazine-heterocyclic side chain
chlorpromazine
Post Operative Nausea & Vomiting:
The Role of Antiemetics - Cedric Dupont-Eisner M.D.
38
Butyrophenones
• Droperidol
– α blocker, D2 receptor antagonist (binds to D2 receptor)
– Acts at both CTZ and area postrema
– 1.25 mg droperidol given at the beginning of surgery is as effective as 4 mg
dexamethasone or 4 mg ondansetron ( Apfel et al. New Engl J Med 2004 ).
– SIDE EFFECTS: EPS, sedation, QTc prolongation with torsade de
pointes (there is little evidence that antiemetic doses trigger this condition
- Gan et al. Anesthesiology 2002).
- high doses: hypotension (a blockade)
- low-dose droperidol may cause dysphoria (Melnick et al. Anesth
Analg 1989, Lim et al. Anaesth Intensive Care 1999)
EPS = extrapyramidal symptoms
Post Operative Nausea & Vomiting:
The Role of Antiemetics - Cedric Dupont-Eisner M.D.
39
Anesthesiology, Vol.102, Number 6, June 2005
40
Benzamide
• Metoclopramide
–
–
–
–
Specific dopamine D2 antagonist
 LES tone which enhances gastric motility
Short (1 to 2 hours) duration of action.
SIDE EFFECTS: EPS, restlessness, drowsiness,
fatigue, agranulocytosis, methemoglobinemia,
hypotension and bradycardia (or tachycardia)
• Cisapride (removed from use – cardiac side effects)
EPS = extrapyramidal symptoms
Post Operative Nausea & Vomiting:
The Role of Antiemetics - Cedric Dupont-Eisner M.D.
41
Anticholinergics
• Scopolamine
– Inhibit cholinergic and muscarinic CNS receptors.
– Crosses the blood-brain barrier.
– More effective against motion-induced emesis than
against motion-induced nausea.
– SIDE EFFECTS: sedation, CNS excitation, dry
mouth, urinary retention, blurred vision, confusion,
disorientation, hallucinations
Post Operative Nausea & Vomiting:
The Role of Antiemetics - Cedric Dupont-Eisner M.D.
Night Shade = Atropa belladonna
42
Antihistamines
• Dimenhydrinate, Hydroxyzine, Cyclizine
– Block acetylcholine in the vestibular apparatus and
histamine H1 receptors in the nucleus of the solitary
tract.
– SIDE EFFECTS: blurred vision, urinary retention,
dry mouth, and sedation
Cyclizine has similar efficacy to ondansetron;
side effects: sedation and dry mouth
(anticholinergic).
Br J Anaesth 2000; 85(5):678-682/ Ahmed AB, Hobbs GJ, Curran JP: “Randomized,
placebo-controlled trial of combination antiemetic prophylaxis for day-case gynaecological laparoscopic surgery”.
Post Operative Nausea & Vomiting:
The Role of Antiemetics - Cedric Dupont-Eisner M.D.
43
5-HT3 Antagonists
• (Ondansetron (Zofran®), Granisetron
(Kytril®), Tropisetron (Navoban®), and
Dolasetron (Anzemet®)
•
- No difference in efficacy
– No sedation, extrapyramidal reactions, adverse effects on
vital signs or laboratory tests, or drug interactions with
other anesthetic medications.
–
Because repeating ondansetron is of limited effectiveness (Kovac et al. J
Clin Anesth 1999) - reasonable to use ondansetron predominantly as a rescue
treatment ( White PF, New Engl J Med 2004)
– SIDE EFFECTS: Headache, dizziness,
flushing, elevated liver enzymes, constipation
Post Operative Nausea & Vomiting:
The Role of Antiemetics - Cedric Dupont-Eisner M.D.
Management of PONV’ – Habib et al / CAN J ANESTH; 2004; 51:4; pp 326 - 341
44
Ondansetron Pharmacokinetics
45
www.anzemet.com/images/chart_c_pharmacology.jpg
46
“Management of PONV’ – Habib et al / CAN J ANESTH; 2004; 51:4; pp 326 - 341
47
Dexamethasone
Synthetic steroid
Hypotheses
• inhibition of prostaglandin syn.
•  tryptophan
• release of endorphins
• change in CSF opening pressure
• + psychological effects of steroids
ACUTE SIDE EFFECTS: flushing
and perineal itching.
- Wang et al. Anesth Analg 2000 and the IMPACT data
(unpublished observation) - dexamethasone has a delayed onset
of antiemetic actions which might need a few hours to work.
Post Operative Nausea & Vomiting:
The Role of Antiemetics - Cedric Dupont-Eisner M.D.
48
Dexamethasone (contin.)
“Management of PONV’ – Habib et al / CAN J ANESTH; 2004; 51:4; pp 326 - 341
49
“Management of PONV’ – Habib et al / CAN J ANESTH; 2004; 51:4; pp 326 - 341
50
NK1 Antagonists
• Future development in anti-emesis is looking at the neurokinin
1 (NK-1) receptor, where substance P is the natural ligand. This
receptor is found in the nucleus tractus solitarius and the area
postrema, as well as the peripheral nervous system. Early
studies of NK-1 antagonists have been promising, especially in
combination with ondansetron. (World Federation of Societies of Anaesthesiologists
WWW implementation by the NDA Web Team, Oxford ; Issue 17 (2003) Article 2: Page 1 )
• Neurokinine (substance P, NK1) antagonists - impressive
antiemetic in the animal model. However, early clinical data have
been disappointing, except for aprepitant (Emend®) - has
demonstrated superiority over ondansetron in chemotherapy induced
nausea and vomiting.
http://www.ponv.org/Knowledge.htm
51
DRONABINOL Marinol®
– 9THC
– Unknown mechanism
involves inhibition of
CTZ
– SIDE EFFECTS:
dizziness, drowsiness,
nausea (not emesis)
– Schedule II drug
Post Operative Nausea & Vomiting:
The Role of Antiemetics - Cedric Dupont-Eisner M.D.
www.marinol.com/images/chart-clinical1.gif
References: 1. Beal JE, et al. J Pain Symptom Manage. 1995;10(2):89-97. 2. Beal JE, et al. J Pain
Symptom Manage. 1997;14(1):7-14.
52
Nonpharmacological Methods
(TENS) for Prevention of PONV
C K. Sim http://www.iars.org/abstracts/abstracts/S160/s180.htm
53
Accupressure Wristbands for PONV
Accupressure Wristbands do not Prevent PONV after Urological
Endoscopic Surgery – A. Agarwal et al. – Can J Anesth 2000/ 47:4/ p319324
54
Ginger root
• Ginger root (Zingiber
officinale Roscoe.,
Zingiberaceae)
• "In summary, we found
that ginger is a
promising antiemetic
herbal remedy, but the
clinical data to date are
insufficient to draw firm
conclusions.“
Phillips S, Ruggier R, Hutchinson SE. Zingiber officinale (Ginger) - an antiemetic for day case surgery. Anaesthesia 1993; 48: 715-717
Postoperative nausea (Bone et al., 1990; Phillips et al., 1993; Arfeen et al., 1995)
55
• Aromatherapy With Peppermint , Isopropyl
Alcohol or Placebo is Equally Effective in
Relieving Postoperative Nausea
Lynn AA, Jeffrey GB (2004)
www.safehomeproducts.com/SHP/HH/ReliefBand.asp
56
Vestis K is a vestibular
stimulator specially designed for
clinical use, integrating current
display and separate current
monitoring with alarm functions
for both electrodes.
INDICATIONS
Hyperemesis gravidarum
postoperative Nausea
Nausea after Chemo- and
Radiotherapy
Travel Sickness
im.edirectory.co.uk/products/1816/i/6601042.jpg
www.biegler.com/vestis.en.html
57
Noni CAPSULE
Item Code : c017
Morinda citrifolia Linn.
Morinda CAPSULE
Each : 500 mg. Indication : for symptomatic relief of
nausea and vomiting Dosage : 1-2 capsules each
time , 3 times a day , before meal Packing : 50
Vcaps.Contained in Plant product qualified
capsules. Passed national GMP evaluation. PRICE
US$ 9.60 (excl. shipping)
58
HANUMAN PRASANKAI TEA
Item Code : h011
Schefflera leucantha Vig.
Herbal Tea for Health
Each : Hanuman prasankai 100 %
Indication : Relieves cough and nausea,
Used as bronchodilator
Content : 20 sachets.
Net. weight 20 g.
Price : US$ 2.90 (excl. shipping
59
Enterra Therapy
Gastric Electrical Stimulation (GES)
The implantable stimulation system for
Enterra Therapy is shown in Figure 1 and is
comprised of the following:
Medtronic ITREL 3 Model 7425G
Neurostimulator
The ITREL 3 is a battery powered
implantable device that is commercially
available in the U.S.
Medtronic Model 4351 Lead
The new 4351 Intramuscular Lead is a
unipolar lead intended for use with an
implantable neurostimulator. The 4351 lead
has a ski needle design for easier use with
laparoscopic procedures. It is also designed
with a fixed electrode length of 1 cm. The
4351 lead connects directly to the
neurostimulator and is available in 35 cm
length. Two leads are used in each patient.
www.medtronic.com/.../images/chart_study.gif
60
The main sites of action of drugs
affecting nausea and vomiting
61
Summary table Relating Type of Nausea, Receptor,
Drug Class, and Example of Drug of Choice
Type of Nausea
Receptors
Causing
Nausea
Drug Class Useful
Examples of DOC
Vestibular
Cholinergic,
histaminic
Anticholinergic,
antihistaminic
Scopolamine
patch,
promethazine
Obstruction of bowel
caused by constipation
Cholinergic,
histaminic, ?
5HT3
Stimulate myenteric
plexus
Senna products
DysMotility of upper gut
Cholinergic,
histaminic, ?
5HT3
Prokinetics
stimulate 5HT4
receptors
Metoclopramide
Infection, Inflammation
Cholinergic,
histaminic, ?
5HT3
Anticholinergic,
antihistaminic
Promethazine,
prochlorperazine
Toxins stimulating the
CTZ in the brain such as
opioids
Dopamine 2,
5HT3
Antidopaminergic,
5HT3 antagonist
Prochlorperazine,
haloperidol,
ondansetron
http://www.mywhatever.com/cifwriter/library/70/4938.html
62
www.uspharmacist.com/index.asp?show=article&p...
63
Individual Risk Factors for PONV
64
Algorithm for PONV Prophylaxis
Evaluate risk of PONV
in surgical patient
Low
No prophylaxis
unless there is
medical risk of
sequelae from
vomiting
Moderate
High
Consider regional
anesthesia
Not indicated
If general anesthesia is used, reduce baseline risk factors when
clinically practical & consider using nonpharmacologic therapies
Patients at
moderate risk
Consider antiemetic prophylaxis
with monotherapy (adults) or
combination therapy
(children and adults)
Gan TJ et al. Anesth Analg. 2003;97:62–71.
Patients at
high risk
Initiate combination therapy
with 2 or 3 prophylactic
agents from
different classes
65
www.allaboutpharmacy.co.uk/Formulary/ponv.jpg
66
PONV Treatment Pathway
-Mass. General Protocol for PONV
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Step 1.
Ondansetron 2 mg IV and dexamethasone 4 mg IV as a single dose
If nausea and vomiting continues to be problematic after 30 minutes, proceed to step 2:
Step 2.
For the MGH only:
Haloperidol 0.25mg IV, may repeat times one in 30 minutes, or
Ephedrine 50 mg IM (35 mg for patients < 50 Kg). May be repeated x1 in 4 hours
*contraindicated in patients with cardiovascular or hypertensive disease*
and
Metoclopramide 20 mg IV. May be repeated x1 in 4 hours
If nausea and vomiting continues to be problematic after 30 minutes, proceed to step 3:
Step 3.
Promethazine 12.5 -25 mg IV q 4 h. or
Meclizine 25mg orally q 8 h. or
Prochlorperazine suppository 25 mg per rectum q 12 h.
If nausea and vomiting continues to be problematic, proceed to step 4:
Step 4.
Droperidol
Prior to prescribing droperidol, physician must determine that pre-administration EKG QTc interval is < 440
msec [males] or <450 msec [females]. If within guidelines, then
*Give droperidol 1.25 mg IV x 1 dose only
*Patient's EKG must be monitored for 2-3 hr post-dose.
Note: These guidelines were developed by an interdisciplinary group of clinicians from the BWH and MGH Pharmacy and
Anesthesia Departments.
http://www.massgeneral.org/pharmacy/Newsletters/2002/March%202002/Postoperative%20Nausea%20and%20Vomiting.htm
67
Treatment of Established PONV
68
What is the Best Strategy to Prevent PONV?” – A.S. Habib and T.J. Gan; Chapter
pp130-135; in Evidence-based Practice of Anesthesiology – Lee A. Fleisher, 2004
69
“Management of PONV’ – Habib et al / CAN J ANESTH; 2004;
51:4; pp 326 - 341
70
Bibliography
•
•
•
•
•
•
•
•
•
http://www.nauseaandvomiting.co.uk/NAVRES001-2-NandV-general.htm
Maddali MM, Mathew J, Fahr J, Zarroug AW. Postoperative Nausea and Vomiting in Diagnostic Gynaecological
Laparoscopic Procedures: Comparison of the Efficacy of the Combination of Dexamethasone and Metoclopramide
with that of Dexamethasone and Ondansetron .J Postgrad Med 2003;49:302-306
http://faq.emetophobia.net/
http://www.eddyelmer.com/tools/aemetic.htm
“Clinical Anesthesia Practice” – R. R. Kirby, N. Gravenstein, E. B. Lobato, J. S. Gravenstein; 2nd edition 2002, p.114
“Strategies for Maximizing The Efficacy of Antiemetics In PONV Therapy” - Special Report – May 01, 2005
Post Operative Nausea & Vomiting: The Role of Antiemetics - Cedric Dupont-Eisner M.D.
Evidence-based management of PONV: a review – A.S. Habib, T.J. Gan – CAN J ANESTH 2004 / 51:4 / pp326 – 341
“Antiemetics” , J Scholz, MD, PhD, M Steinfath, MD, PhD, PT Tonner, MD, Phd p777 – 791; in Anesthetic Pharmacology, AS Evers and M
Maze, 2004
Further Readings:
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In English:
• Watcha MF. Postoperative nausea and vomiting. Anesthesiol Clin N Am 2002; 20: 709-20.
• Kovac AL. Prevention and treatment of postoperative nausea and vomiting. Drugs 2000; 59: 213-43.
• Gan TJ et al. Consensus guidelines for management of postoperative nausea and vomiting. Anesth Analg 2003; 97:6271.
In Deutsch:
• Apfel CC, Roewer: Postoperative Uebelkeit und Erbrechen. Anaesthesist 2004; 53:377-391. PDF-File
• Eberhart LHJ et al.: Minimierung von Uebelkeit und Erbrechen in der postoperativen Phase. Dtsch Arztebl 2003;
1000: A 2584-2591 [Heft 40].
En Francais:
Pierre S, Corno G: Nausees et vomissements postoperatoires de l'adulte. Ann Fr Anesth Reanim 2003;22:119-129.
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