Update on the Management of Postoperative Nausea and Vomiting

Abstract

New antiemetic drug developments, formulations, guidelines, risk evaluation, and controversies have occurred in the area of postoperative nausea and vomiting (PONV). These developments have helped improve our understanding of the prevention and treatment of PONV in the postanesthesia care unit and after discharge home or to the hospital ward. Antiemetic drug research has resulted in the introduction of the second-generation 5-hydroxytryptamine-3 (5-HT3) receptor antagonist palonosetron and the neurokinin-1 (NK-1) receptor antagonist aprepitant, as well as new data on existing antiemetics. The next frontier and need for further nausea and vomiting research and therapy is the area of postdischarge nausea and vomiting after the patient is discharged home from phase II of the ambulatory stepdown unit or to the hospital ward. Antiemetic drug selection depends on efficacy, cost, safety, and ease of dosing. Safety concerns have arisen regarding the side effects of antiemetics, specifically their effect on the ECG with prolongation of the QTc interval by the butyrophenones and the first-generation 5-HT3 receptor antagonist class of antiemetics. The impact of pharmocogenetics on antiemetic drug metabolism and their resulting efficacy has been correlated with genetic makeup affecting drug response. A discussion of ethics in PONV research has been initiated by the meta-analysis of PONV studies. To help guide antiemetic selection and PONV therapy for clinical practitioners, the Society of Ambulatory Anesthesia (SAMBA) PONV consensus guidelines have been introduced and updated.

Aprepitant: A New Modality for the Prevention of Postoperative Nausea and Vomiting: An Evidence-Based Review

“…Over the first 24 hours, the study found aprepitant 40 mg orally to be superior to ondansetron 4 mg IV on all five end points: (1) no significant nausea (defined as a peak score #4), (2) no nausea, (3) no vomiting, (4) no nausea and no vomiting, and (5) no nausea, no vomiting, and no use of rescue therapy (P , .035 for the odds ratio). Numerically, patients receiving aprepitant 125 mg orally as compared with ondansetron 4 mg IV achieved the five end points mentioned previously.…”

“…[1][2][3][4] PONV can increase health care costs related to unanticipated admissions and delayed postanesthesia care unit (PACU) or hospital discharge. 3 Risk factors for PONV are described as based on three categories: patientspecific, anesthetic related, and surgery related. 1 Patient-specific risk factors include female gender, nonsmoking status, and a history of PONV and/or motion sickness.…”

“…Lowering the incidence of PONV will potentially lower its costly and disastrous consequences such as fluid and electrolyte imbalance, surgical wound dehiscence, hemorrhage, aspiration pneumonia, delayed discharge, and hospital readmission. 3,4,6,7 In high-risk patients, research has shown that management should consist of a prophylactic rather than therapeutic approach. 1,2 Medications generally target the receptor-mediated triggers of PONV, although its origins are poorly understood.…”

“…[2][3][4][5]7 NK1 receptors exist peripherally and centrally and combine themselves with substance P. Substance P is an endogenous ligand for NK1 receptors and plays a significant role in the vomiting center. 4,9 The combination of substance P and NK1 receptors produces a reaction in the vomiting center in the brain and gastrointestinal tract.…”

Postoperative Care of Patients Undergoing Same‐Day Laparoscopic Cholecystectomy

“…11 Managing PONV requires knowledge of emetogenic pathways and the correct timing and combination of antiemetics. In 2013, the Society for Ambulatory Anesthesia (SAMBA) 14 published research-based PONV guideline updates for choosing appropriate antiemetic regimens for patients with PONV. Despite the growing number of emetogenic pathway neurotransmitters that have been identified, multiple pharmacological modalities used in combination provide better outcomes than single treatments or no treatment.…”