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Postoperative Nausea and Vomiting—
Can It Be Eliminated?
Tong J. Gan, MB
POSTOPERATIVENAUSEAANDVOM- paratus,cerebellum,solitarytract Risk Factor Identification
tient, surgical, and anesthetic factors.
that female sex, a history of motion sick- shorter-acting anesthetic drugs, have re- the presence of 0, 1, 2, 3, or all 4 of these patients,3,4 and pediatric populations are tiemetic in adults, with an adverse effect during anesthesia, including opioids, ni- trous oxide, and volatile inhalational an- perazine, are effective but associated with PONV is rarely fatal, it is an unpleasant postoperative symptom (BOX). Even
risk factors, are presented in the FIGURE.
charge, decrease patient satisfaction, and Combination Antiemetics
mines, cyclizine is effective, although it one study, patients were willing to spend ing on different receptors can further re- Physiology of and
Author Affiliation: Department of Anesthesiology,
Pharmacology for PONV
Duke University Medical Center, Durham, NC.
Financial Disclosure: Dr Gan has received grant
support and honoraria from Abbott, Aventis, GlaxoSmithKline, Novartis, and Roche.
Corresponding Author and Reprints: Tong J. Gan, MB,
fects.16,17 It is important to distinguish Department of Anesthesiology, Duke University Medi- cal Center, Box 3094, Durham, NC 27710 (e-mail: ter is an ill-defined area located in the
Contempo Updates Section Editor: Janet M. Torpy,
2002 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 13, 2002—Vol 287, No. 10 1233
greater effectiveness than a single agent.20 asone (Ͻ8 mg) appears to be safe, largerdoses and prolonged use may cause ad- Box. Recommended Strategies for Minimizing the Incidence
of Postoperative Nausea and Vomiting
and can develop following relatively brief corticosteroids.24 In a recent warning by Antiemetics (consider combination therapy) Total intravenous anesthesia with propofolAdequate hydration Effective analgesia incorporating local anesthetics and inhibitors of Intraoperative supplemental oxygen (FIO Ն *Although opioids are emetogenic, optimal analgesia should be the goal and can be achieved by incorporating preoperative education, local anesthetics, and inhibitors of cyclooxygen- ase 2. Optimal analgesia may include an opioid.
Medicines Control Agency, part of theDepartment of Health in the UnitedKingdom, did not mandate electrocar- Figure. Risk Factors for PONV and Guidelines for Prophylactic Antiemetic Therapy
diographic monitoring with the use ofdroperidol perioperatively.26 In the 31years of droperidol use, there has not Patient Factors
Surgical Factors
tion, arrhythmias, or cardiac arrest.
trapolate that use of multiple (Ͼ2) drug combinations will further enhance ef-fectiveness, published evidence isscarce. Scuderi et al26 showed that mul-timodal management incorporatingcombination antiemetics and propo- Mild to Moderate Risk
Moderate to High Risk
Very High Risk
sponse rate. A high concentration ofoxygen as an antiemetic is a use that few appreciate.27,28 Greif et al27 used intra- intraoperatively. The use of 80% oxy-gen intraoperatively as a component ofgeneral anesthesia significantly re- Based on references 3 and 38. PONV indicates postoperative nausea and vomiting. Percentages denote risk ofdeveloping PONV. Consideration should be given to avoid risk factors associated with PONV and other strat- egies (Box) to further reduce the incidence. Serotonin antagonists may be preferred antiemetics in operative settings where nursing labor costs are directly related to the length of postanesthesia care unit stay.
1234 JAMA, March 13, 2002—Vol 287, No. 10 (Reprinted)
2002 American Medical Association. All rights reserved.
centration or the decrease in nitrous ox- sea and vomiting or adverse effects of an- are more likely to be directly related to stay in an office-based setting and, to a fective after discharge. There is a lack of effective over-the-counter antiemetics.
sia care unit stay may not have a signifi- ing staff can be reduced. In light of the pofol’s action as an antiemetic has not ther investigation of the cost-effective- ness of other therapies is required.
Future Development
The natural ligand of the neurokinin 1(NK-1) receptor, substance P, is found Complementary Techniques
Cost-effectiveness of Antiemetics
in the nucleus tractus solitarius and the out actually needing it, while others will radialis and palmaris longus tendons.
inefficient use of resources.41 In a cost- laxis with ondansetron in all patients is Postdischarge Nausea
and Vomiting
this trend is increasing.36 Postoperative effective and associated with greater pa- 2002 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 13, 2002—Vol 287, No. 10 1235
antiemetics should be considered (Box).
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