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SOGC CLINICAL PRACTICE GUIDELINE
SOGC CLINICAL PRACTICE GUIDELINE
Guideline for the Management of Postoperative
Nausea and Vomiting
2. When the choice is available, patients should be advised that the risk of PONV decreases when regional rather than general This guideline has been approved by Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.
3. The perioperative use of opioids should be minimized. Surgeons PRINCIPAL AUTHORS
should evaluate the risks/benefits of opioid administration in light 4. Prophylactic antiemetics should be administered to patients with moderate or high risk of developing PONV. (II-1A) 5. In patients with a high risk of developing PONV, combination antiemetic therapy should be considered. (III-B) Abstract
6. Acupoint electrical stimulation may be used as an alternative or adjuvant therapy for prevention of PONV. (II-1A) Objective: To provide recommendations for the management of
postoperative nausea and vomiting (PONV), which may affect as 7. For patients with PONV who did not receive prophylaxis or in whom prophylaxis failed, antiemetic treatment should beadministered as soon as feasible. (III-A) Methods and Evidence: Medline, PubMed, and the Cochrane
Database were searched for articles published in English from 8. When prophylaxis with one drug has failed, a repeat dose of this 1995 to 2007. Recognizing that we must work as a team to drug should not be initiated as a rescue therapy; instead, a drug optimize the care of our patients perioperatively, this guideline was from a different class of antiemetic drugs should be written in partnership with anaesthesiologists.
Options: The areas of clinical practice considered in formulating this
9. As patients who undergo surgery in surgical daycare units may guideline are prevention and prophylaxis, treatment, both medical have PONV after they are discharged, they should be given and alternative, and patient education.
Outcomes: Implementation of this guideline should optimize the
10. Patients at high risk of developing PDNV should be provided with prevention of and prophylaxis against PONV and the prompt treatment of women who suffer from PONV following gynaecologic J Obstet Gynaecol Can 2008;30(7):600–607 surgery. Increased awareness of options for management shouldhelp minimize the effects of PONV.
INTRODUCTION
Benefits, Harms, and Costs: PONV results not only in increased
patient discomfort and dissatisfaction but also in increased costsrelated to length of hospital stay. Cost of medications to prevent Postoperative nausea and vomiting, defined as nausea and treat PONV must be weighed against improved surgical and/or vomiting occurring within 24 hours after sur- experience for the patient and decreased costs to the system.
gery, affects between 20% and 30% of patients.1–4 As many Values: Recommendations were made according to the guidelines
as 70% to 80% of patients at high risk may be affected.5 The developed by the Canadian Task Force on Preventive Health etiology of PONV is thought to be multifactorial, involving individual, anaesthetic, and surgical risk factors.2,5,6 PONV Recommendations
results in increased patient discomfort and dissatisfaction6 1. Physicians should be aware of the risk factors associated with PONV, and the baseline risks should be reduced whenever and in increased costs related to length of hospital stay. One study revealed that the time to discharge was increased by25% in patients with PONV.7 Serious medical complica-tions such as pulmonary aspiration, although uncommon,are also associated with vomiting.6 Key Words: Postoperative nausea, postoperative vomiting
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information
should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate
amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be
reproduced in any form without prior written permission of the SOGC.
l JULY JOGC JUILLET 2008
Guideline for the Management of Postoperative Nausea and Vomiting
Table 1. Key to evidence statements and grading of recommendations, using the ranking of the
Canadian Task Force on Preventive Health Care
Evidence obtained from at least one properly randomized A. There is good evidence to recommend the clinical preventive II-1: Evidence from well-designed controlled trials without B. There is fair evidence to recommend the clinical preventive II-2: Evidence from well-designed cohort (prospective or C. The existing evidence is conflicting and does not allow to retrospective) or case-control studies, preferably from more make a recommendation for or against use of the clinical preventive action; however, other factors may influencedecision-making II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in D. There is fair evidence to recommend against the clinical uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this E. There is good evidence to recommend against the clinical III: Opinions of respected authorities, based on clinical L. There is insufficient evidence (in quantity or quality) to make experience, descriptive studies, or reports of expert a recommendation; however, other factors may influence *The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Forceon Preventive Health Care.75†Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the The CanadianTask Force on Preventive Health Care.75 PONV is a significant problem for patients: in one study, afferent pathways involved in stimulating the vomiting cen- patients were more concerned about PONV than about postoperative pain8; in another, patients were willing to spend up to US $100 for an effective antiemetic treatment.9 2. the vagal mucosal pathway in the gastrointestinal system, Several thousand studies examining PONV have been pub-lished, and several hundred new papers are published each 3. neuronal pathways from the vestibular system, year on the topic. Guidelines for the prevention and man- 4. reflex afferent pathways from the cerebral cortex C2,3, agement of PONV have been published by anaesthetic Management of PONV for gynaecological patients in mosthospitals continues to be on an ad hoc basis. The aim of Stimulation of one of these afferent pathways can activate these guidelines is to provide information on the manage- ment of PONV in gynaecological patients.
dopaminergic, histaminergic, or serotonergic receptors.
PHYSIOLOGY OF NAUSEA AND VOMITING
MANAGEMENT OF PONV
Primary control of nausea and vomiting arises from the Reduction in Baseline Risk Factors
vomiting centre, located in the medulla. The five primary Blanket use of PONV prophylaxis is not cost-effective andunnecessarily risks drug-related adverse effects. Mostguidelines are in agreement that patients at low risk forPONV are unlikely to benefit from prophylaxis and that itshould be reserved for patients at moderate to high risk.
ABBREVIATIONS
Patients with no more than one risk factor are considered low risk. Identifying patient risks remains a challenge.
Apfel et al.13 devised a simplified risk score for predicting PONV. They concluded that there are 4 main risk factors: NSAIDs nonsteroidal anti-inflammatory drugs 2. prior history of motion sickness or PONV, JULY JOGC JUILLET 2008 l
SOGC CLINICAL PRACTICE GUIDELINE
Recommendations
4. the use of postoperative opioids.
2. When the choice is available, patients should be advised that the risk of PONV decreases when regional rather The estimated probability of PONV was 10%, 21%, 39%, than general anaesthesia is administered. (III-A) and 78% with 0, 1, 2, 3, and 4 risk factors, respectively.
3. The perioperative use of opioids should be minimized.
Surgeons should evaluate the risks/benefits of opioid Risk Factors for PONV
administration in light of the increased risk of PONV. (III-B) These can de divided into 3 main groups:
• Patient-specific: female sex8,13; non-smoker13,14;
Pharmacological Prophylaxis
history of PONV or motion sickness.13–15 Prophylactic doses and timing for the administration of • Anaesthetic: use of volatile anaesthetics within 0 to
2 hours16; use of nitrous oxide17; use of intraoperative Serotonin (5-HT3) receptor antagonists exert their effects in and postoperative opioids13,18–21; high doses of the chemoreceptor trigger zone and at vagal afferents in the gastrointestinal tract. Ondansetron was the first of this class • Surgical: duration of surgery, with each 30-minute
of drug to be marketed; others include dolasetron, increase in duration increasing the risk of PONV by In 2003, an expert panel agreed that there was no evidence Recommendation
of any difference in the efficacy and safety profiles of the 1. Physicians should be aware of the risk factors associated different 5-HT3 receptor antagonists in the prophylaxis with PONV, and the baseline risks should be reduced against PONV.10 Ondansetron 4 mg has a NNT of 7 for the prevention of nausea and 6 for the prevention of vomiting.
The number needed to harm with a single dose of Optimization in the Perioperative Period
ondansetron is 36 for headache, 31 for increased liver A number of perioperative factors have been shown to Dexamethasone, a corticosteroid, administered at a dose of8–10 mg IV, prevents PONV with a NNT of 4.38 Smaller When possible, regional anaesthetic should be administered doses of 2.5–5 mg have been shown to be as effective13,40 as general anaesthetic is associated with an 11-fold The precise mode of action is not well understood, but may increased risk of PONV.22 When general anaesthetic is be due to the release of endorphins that elevate mood and required, the use of propofol as the induction agent is effec- stimulate appetite.16 There are no reports of adverse effects tive in reducing early PONV incidence when compared in the doses used for the management of PONV.38 with other induction agents. The number needed to treatwith propofol to reduce PONV is approximately 5.23 Droperidol blocks dopamine receptors in the CTZ. Theefficacy of droperidol is equivalent to that of ondansetron, Avoidance of intraoperative and postoperative opioids has with a NNT of 5 for prevention of PONV. The FDA issued been shown to reduce PONV. Moiniche et al. showed that a “black box” warning about droperidol, stating that it may treatment with NSAIDs as compared with opioids cause death associated with QT prolongation and torsades decreased the risk of PONV.20 The use of supplemental
de pointes. In Canada, droperidol is still available but its use oxygen perioperatively has been shown to reduce PONV by 50%.24,25 possibly by reducing gastrointestinal hypoxia.
However, there is conflicting evidence, and a recent study Metoclopramide blocks dopamine receptors in the CTZ by Turan et al. demonstrated no benefit associated with and vomiting centre. It also shortens bowel transit time and in high doses blocks serotonin receptors. When used instandard clinical doses of 10 mg, metoclopramide was Perioperative intravenous fluid administration has been found to be ineffective for PONV prophylaxis.49 A dose of shown to reduce PONV.27,28 The mechanism is unclear but 50 mg intravenous metoclopramide has been shown to sig- may be related to the release of serotonin due to decreased nificantly reduce late (> 12 hours) PONV, but the side intestinal perfusion, which can be caused by the drop in sys- effect profile is unsatisfactory.47 The guidelines produced tolic blood pressure seen with some induction agents.
by Gan et al. do not recommend metoclopramide as a Neostigmine, a reversal agent for non-depolarising muscle relaxants, is associated with increased PONV, especially in Dimenhydrinate, a commonly used antihistaminic, has sim- large doses (> 2.5 mg),29 and should be avoided if possible.
ilar efficacy to 5-HT3 receptor antagonists.43 Its efficacy is l JULY JOGC JUILLET 2008
Guideline for the Management of Postoperative Nausea and Vomiting
Table 2. Prophylactic doses and timing for the administration of antiemetics
Headache, lightheadedness, elevatedliver enzymes Headache, lightheadedness, elevatedliver enzymes Headache, lightheadedness, elevatedliver enzymes Headache, lightheadedness, elevatedliver enzymes Vaginal itching or anal irritation with IVbolus Sedation, dizziness, anxiety,hypotension, EPS Sedation, dry mouth, blurred vision,dizziness, urinary retention disturbances; CNS effects in elderlypatients, renal or hepatic impairment Before induction, morning ofsurgery, 1 tablet presumably due to the high concentration of histamine and antiemetic properties found in over-the-counter sleeping muscarinic cholinergic receptors within the vestibular medication) and 10 mg pyridoxine hydrochloride (vitamin B6), in a delayed release formulation. Pyridoxine may haveintrinsic antiemetic properties and also may be synergistic Promethazine and prochlorperazine belong to a group of with the antinauseant property of antihistamines.54–56 drugs known as phenothiazines, which act primarily via a Diclectin has been used since the 1950s and is considered to central antidopaminergic mechanism in the CTZ. The use be a safe treatment for nausea and vomiting associated with of these drugs has decreased because of their significant pregnancy.57 The International Cochrane Collaboration has side effects: sedation, dizziness, and extrapyramidal systematically reviewed randomized trials of Diclectin and concluded that it safely provides considerable relief for nau- Scopolamine is an anticholinergic that blocks emetic muscarinic receptors in the cerebral cortex.51 It is veryeffective, with a NNT of 3.8 for prevention of PONV.52 Its Aprepitant was the first neurokinin-1 (NK-1) receptor use is limited because of its two- to four-hour onset of antagonist approved for the treatment of PONV. This drug effect and side effect profile as listed above.
blocks NK1 receptors in the central and peripheral nervoussystems thus preventing emesis. In one study, patients given A recent publication has shown Diclectin to be as effective oral aprepitant alone or in combination with intravenous as ondansetron for the prevention of late postoperative ondansetron had significantly fewer emetic episodes than vomiting in women undergoing laparoscopic tubal ligation, those given ondansetron alone.59 In a report of combined data from 2 large trials, oral aprepitant 40 mg was superior Diclectin is an antiemetic medication that contains 10 mg to intravenous ondansetron 4 mg for the prevention of doxylamine succinate (a common antihistamine with PONV.60 Complete response (no nausea, vomiting, or need JULY JOGC JUILLET 2008 l
SOGC CLINICAL PRACTICE GUIDELINE
for rescue therapy) was achieved in 37.9% of the aprepitant Non-pharmacologic Prophylaxis
group compared with 31.2% of the ondansetron group. Itsacquisition cost is relatively high, making it less appealing as Acupuncture has been shown to be effective in the manage- ment of PONV. Coloma et al.65 compared acustimulationwith ondansetron for the treatment of established PONV None of the available agents is entirely effective for pre- in outpatient laparoscopic surgery patients. They concluded venting PONV, particularly for high-risk patients. As there that acustimulation may be a satisfactory alternative to are four major receptor systems involved in the etiology of ondansetron for established PONV, and that ondansetron PONV, a combination of agents that act on different recep- seems to enhance the efficacy of acustimulation for treat- tors results in better prophylaxis.61,62 The most commonly studied combinations have included 5-HT3 receptor antag-onists with droperidol or dexamethasone, and both are Ginger root is a commonly used non-medical therapy equally efficacious.63,64 The Figure illustrates a proposed but is not effective for PONV prophylaxis.66 Similarly, cannabinoids have not been confirmed to be effective in the Recommendations
4. Prophylactic antiemetics should be administered to Recommendation
patients with moderate or high risk of developingPONV. (II-1 A) 6. Acupoint electrical stimulation may be used as an 5. In patients with a high risk of developing PONV, combi- alternative or adjuvant therapy for prevention of nation antiemetic therapy should be considered. (III-B) l JULY JOGC JUILLET 2008
Guideline for the Management of Postoperative Nausea and Vomiting
Rescue Treatment for PONV
In a study by Gan et al.73 4 mg IV ondansetron for PONV In the presence of persistent nausea and vomiting, possible prophylaxis was administered. Patients were then random- contributing factors, such as patient-controlled morphine ized to receive either ondansetron oral disintegrating tablet analgesia, presence of blood in the pharynx, or an abdomi- (ODT) 8 mg or placebo immediately before discharge from nal obstruction, should be excluded before rescue therapy the ambulatory surgery centre and again 12 hours later.
Patients who received ondansetron ODT had less severe When prophylaxis with one drug has failed, a repeat dose of nausea and fewer vomiting episodes (3% vs. 23%) after this drug should not be initiated as a rescue therapy. Instead a drug from a different class of antiemetics should be Al-Sadi et al.74 assessed the efficacy of acupuncture as a pro- administered.67 However, if the PONV occurs more than 6 phylactic antiemetic. They found a significant difference hours after surgery, repeat dosing of the initial prophylactic between groups before and after discharge, with the pla- drug may be considered. Repeat doses of dexamethasone cebo group four times more likely to have post-discharge and transdermal scopolamine should not be administered nausea and vomiting than the acupuncture group.
Recommendations
If a patient has received no prophylaxis, treatment with a 9. As patients who undergo surgery in surgical daycare units 5-HT3 receptor antagonist may be considered.68 Rescue may have PONV after they are discharged, they should treatment doses for 5-HT3 receptor antagonists are be given instructions for its management. (III-B) approximately 25% the dose of those used for prophylaxis(e.g., 1 mg ondansetron).
10. Patients at high risk of developing PDNV should be Recommendations
7. For patients with PONV who did not receive prophylaxis REFERENCES
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Source: http://jogc.ca/abstracts/full/200807_SOGCClinicalPracticeGuidelines_1.pdf