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PONV management guidelines, which I helped author (osmag.net/jTEF6h). Here are
some highlights from the updated recommendations that you should incorpo-
rate into your anesthesia routines.
Identifying likely sufferers
We all know the traditional PONV risk factors: female sex, a history of PONV
or motion sickness, non-smokers and post-op opioids. The new guidelines
add another risk factor to the list: patients younger than 50. You should deter-
mine the need and use of antiemetics on each patient's baseline risk score.
Those with 3 or more of the above risk factors are at high risk of PONV, put-
ting the likelihood that they'd experience it at between 60 and 80%. Although
patients who undergo surgery in the outpatient setting are at lower risk of
PONV, they are at significant risk of experiencing post-discharge nausea and
vomiting (PDNV). In addition to the same risk factors for PONV, patients who
experience nausea in the PACU are most likely to suffer PDNV.
Reducing the baseline risk
Once you know which patients are more likely to suffer PONV, then it's time to
reduce the risk. These interventions have proven effective.
• Limit general anesthesia. Volatile anesthetics and nitrous oxide are among
the most likely causes of PONV. When possible, opt for regional anesthesia
instead of general anesthesia; research has shown that patients who receive
regional anesthesia are 9 times less likely to experience PONV.
• Avoid opioids. Post-op opioids increase the risk of PONV in a dose-depen-
dent manner — one-third of patients treated with powerful painkillers will feel
nauseated. NSAIDs and cyclooxygenase-2 inhibitors help reduce opioid use dur-
ing post-op recovery.
• Add propofol. Combining propofol with total IV anesthesia (TIVA) reduces
PONV risk by 25%. Using propofol during the induction and maintenance of gen-
eral anesthesia decreases the risk of early onset PONV. Administering a 1-mg
