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Postoperative Nausea and Vomiting: Past, Present, and Future
Paul F . White, PhD, MD, FANZCA
Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center,
Dallas, Texas and the Departments of Anesthesia at Policlinico Abano Terme and Parma University in Italy,
and Cedars Sinai Medical Center in Los Angeles
Postoperative nausea and vomiting (PONV) use of longer-acting antiemetics (e.g., transdermal is a long-standing, multi-factorial problem for scopolamine, palonosetron) may offer significant anesthesia practitioners.(1) The incidence of advantages over the commonly used antiemetics PONV remains high despite the frequent use of in preventing PDNV in the post-discharge recovery prophylactic antiemetics (e.g., 5-HT3 antagonists, period. In a comparative study involving ondansetron glucocorticoids, dopamine antagonists), shorter- and droperidol, transdermal scopolamine was found acting anesthetics and analgesics (e.g., propofol, to be as effective as these popular generic antiemetics desflurane, remifentanil), and less invasive surgical for prophylaxis in the early postoperative period even techniques (e.g., laparoscopic procedures). Patient, when applied 60-90 min prior to the start of surgery.16 anesthetic and surgical factors all contribute We know from an earlier study by Scuderi et. al.8 to the persistently frequent incidence of emetic using an aggressive approach involving intravenous symptoms in the postoperative period.1 With the anesthesia with propofol and minimal amounts of increasingly emphasis on earlier mobilization and short-acting opiod analgesics, no nitrous oxide, no discharge (“fast-tracking”) after both minor and neuromuscular blocking or reversal drugs, aggressive major operations,2 postural hypotension and oral IV hydration, triple prophylactic antiemetics opioid containing analgesics are becoming more (ondansetron, droperidol, and dexamethasone), and important contributors to PONV and post-discharge ketorolac for preventative analgesia, can effectively nausea and vomiting (PDNV). In a recent analysis of prevent emetic symptoms even after high outpatient factors influencing postanesthesia recovery, Edler et al.3 reported that the number of episodes of PONV Thus, data from the peer-reviewed literature contributes significantly to prolonging the patient’s suggest that: (1) the efficacy of prophylactic antiemetic drug therapy is dependent on the patient’s Use of antiemetic prophylaxis has been shown to overall risk of PONV; (2) the cost-benefit ratio for improve patient satisfaction and speed of recovery using inexpensive antiemetics (e.g., droperidol, compared to simply treating the symptoms when dexamethasone, ondansetron) is significantly lower they occur in the postoperative period.4–6 Therefore, than using an expensive NK-1 antagonist (e.g., antiemetic drugs are now commonly administered aprepitant [Amend]) and 5-HT3 antagonists (e.g., both at the start and/or the end of surgery to patients palonosetron [Aloxi]; (3) With the addition of each considered to be at increased risk of developing successive therapeutic intervention, the incremental PONV.7 In fact, combinations of antiemetic drugs are antiemetic benefit diminishes. Finally, consideration now routinely administered as part of a multimodal should be given to routinely using equi-efficacious strategy for reducing postoperative emetic symptoms and less costly generic drugs (e.g., droperidol, in “at risk” patient populations.8-10 Apfel et al.11 have ondansetron, dexamethasone, transdermal scopola- developed a simplified scoring system which has mine) and devices (e.g., acupressure bands) as the first favorable discriminating and calibrating properties line of prophylaxis in the ongoing battle to effectively for predicting an individual patient’s risk for eliminate PONV. Other important considerations developing PONV.12 However, the Apfel risk scoring include the prevention of postoperative pain system appears to be more predictive of (<24 h) using non-opioid analgesics an the post-discharge versus late (24–72 h) emetic symptoms.13 A recent period, and insuring adequate hydration as part of publication has also provided preliminary evidence to a multimodal approach during the perioperative support the notion that the type of surgical procedure may also play an important role in determining the In conclusion, a combined multimodal approach patient’s overall risk of developing PONV.14 to preventing PONV will not only improve patient It is obvious from reviewing the literature that satisfaction with their overall surgical experience, but PONV has been far better studied than PDNV.15 also lead to a more rapid resumption of their normal There is a pressing need for additional clinical activities of daily living in the early postdischarge studies evaluating the impact of antiemetic therapies period. Although there are still additional etiologic on PDNV. Oral opioid-containing analgesics for factors, as well as prevention and treatment post operative pain management are a major factor modalities, which need to be further investigated,18 it contributing to the occurrence of nausea and is time for all practitioners to begin routinely utilizing vomiting following discharge from a hospital or existing evidence in the peer-reviewed literature for ambulatory surgery facility. It is possible that the preventing PONV in their clinical practices.
International Anesthesia Research Society. Unauthorized Use Prohibited.
REFERENCES
1.
Watcha MF, White PF. Postoperative nausea and vomiting: its etiology, treatment and prevention. Anesthesiology 1992;77: 162–84 White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F, Fast-Track Surgery Study Group. The expanding role of anesthesiology in fast- track surgery: from multimodal analgesia to perioperative medical Edler AA, Mariano ER, Golianu B, Kuan C, Pentcheva K. An analysis of factors influencing postanesthesia recovery after pediatric ambulatory tonsillectomy and adenoidectomy. Anesth Analg 2007;104:784–9 Tang J, Wang B, White, PF, Watcha MF, Qi J, Wender RH. The effect of timing on ondansetron administration on its efficacy, cost-effectiveness, and cost-benefit as a prophylactic antiemetic in ambulatory setting. Anesth Analg 1999;88:1191–2 Sadhasivam S, Saxena A, Kathirvel S, Kannan TR, Trikha A, Mohan V. The safety and efficacy of prophylactic ondansetron in patients undergoing radical mastectomy. Anesth Analg 1999;89:1340–5 Sennaraj B, Shende D, Hadhasivam S, Ilavajady S, Jagan D. Management of post-strabismus nausea and vomiting in children using ondansetron: a value-based comparison of outcomes. Br J White PF, Watcha MF. Postoperative nausea and vomiting; prophylaxis versus treatment. Anesth Analg 1999;89:1137–9 Scuderi PE, James RL, Harris L, Mims GR. Multimodal antiemetic management prevents early postoperative vomiting after outpatient laparoscopy. Anesth Analg 2000;91:1408–14 Habib AS, White WD, Eubanks S, Pappas TN, Gan TJ. A randomized comparison of multimodal management strategy versus combination antiemetics for the prevention of postoperative nausea and vomiting. 10. White PF. Prevention of postoperative nausea and vomiting- a multimodal solution to a persistent problem. N Engl J Med 11. Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simpli- fied risk score for predicting postoperative nausea and vomiting: 12. Pierre S, Benais H, Pouymayou J. Apfel’s simplified score may favourably predict the risk of postoperative nausea and vomiting. Can 13. Ruiz JR, Kee SS, Frenzel JC, Ensor JE, Selvan M, Riedel BJ, Apfel CC. The Effect of an Anatomically Classified Procedure on Antiemetic Administration in the Postanesthesia Care Unit . Anesth Analg 2010 14. White PF, Sacan O, Nuangchamnong N, Sun T, Eng M. Relationship between risk factors and occurrence of early versus late postoperative emetic symptoms . Anesth Analg 2008; 107; 459-63.
15. Glass PSA, White PF. Practice guidelines for the management of postoperative nausea vomiting: past, present, and future. Anesth 16. White PF, Tang J, Song D, Coleman JE, Wender RH, Ogunnaike B, Sloninsky A, Kapu R, Shah M, Webb T. Transdermal scopolamine: an alternative to ondansetron and droperidol for the prevention of postoperative emetic symptoms. Anesth Analg 2007;104:92–6 17. White PF. [Editorial] Prevention of nausea and vomiting: A multimodal solution to a persistent problem. N Engl J Med 2004; 350: 2511-2.
18. Glass PSA. Postoperative nausea and vomiting: we don’t know everything yet. Anesth Analg. 2010 Feb;110(2):299 International Anesthesia Research Society. Unauthorized Use Prohibited.

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