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Abstract
Objective: To provide recommendations for the management of
postoperative nausea and vomiting (PONV), which may affect as
many as 30% of patients.
Methods and Evidence: Medline, PubMed, and the Cochrane
Database were searched for articles published in English from
1995 to 2007. Recognizing that we must work as a team to
optimize the care of our patients perioperatively, this guideline was
written in partnership with anaesthesiologists.
INTRODUCTION
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.
600
Table 1. Key to evidence statements and grading of recommendations, using the ranking of the
Canadian Task Force on Preventive Health Care
Quality of Evidence Assessment*
Classification of Recommendations
I:
*The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force
on Preventive Health Care.75
Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the The Canadian
Task Force on Preventive Health Care.75
MANAGEMENT OF PONV
ABBREVIATIONS
CTZ
NK-1
NNT
PDNV
1. female sex,
PONV
601
3. non-smoker, and
Recommendations
Timing
Dose
30
Adverse effects
31
At end of surgery
Ondansetron
48 mg IV
Dolasetron
12.5 mg IV32
At end of surgery32
Granisetron
0.351mg IV3335
At end of surgery33,35
Tropisetron
5 mg IV36,37
At end of surgery36,37
Dexamethasone
510 mg IV3840
Before induction41
Droperidol
0.6251.25 mg IV36,37
At end of surgery42
Dimenhydrinate
12mg/kg IV43
Prochlorperazine
510mg IV44
Promethazine
12.525mg IV
44
45,46
Scopolamine
Transdermal patch
Metoclopramide
25 or 50 mg IV for
prophylaxis47
Diclectin
10 mg doxylamine
succinate and 10 mg
pyridoxine hydrochloride
At end of surgery44
At end of surgery44
Before induction
Prior evening, 2 tablets
Before induction, morning of
surgery, 1 tablet
After surgery, 1 tablet
Aprepitant
40 mg PO
603
Non-pharmacologic Prophylaxis
Acupuncture has been shown to be effective in the management of PONV. Coloma et al.65 compared acustimulation
with ondansetron for the treatment of established PONV
in outpatient laparoscopic surgery patients. They concluded
that acustimulation may be a satisfactory alternative to
ondansetron for established PONV, and that ondansetron
seems to enhance the efficacy of acustimulation for treatment of established PONV.
Ginger root is a commonly used non-medical therapy
but is not effective for PONV prophylaxis.66 Similarly,
cannabinoids have not been confirmed to be effective in the
management of PONV.
Recommendation
6. Acupoint electrical stimulation may be used as an
alternative or adjuvant therapy for prevention of
PONV. (II-1 A)
605
32. Graczyk SG, McKenzie R, Kallar S, Hickok CB, Melson T, Morrill B, et al.
Intravenous dolasetron for the prevention of postoperative nausea and
vomiting after outpatient laparoscopic gynecologic surgery. Anesth Analg
1997;84:32530.
33. Wilson AJ, Diemunsch P, Lindeque BG, Scheinin H, Helbo-Hansen HS,
Kroeks MV, et al. Single-dose IV granisetron in the prevention of
postoperative nausea and vomiting. Br J Anaesth 1996;76:5158.
34. Cieslak GD, Watcha MF, Phillips MB, Pennant JH. The dose response
relation and cost-effectiveness of granisetron for the prophylaxis of
pediatric postoperative emesis. Anesthesiology 1996;85:107685.
35. Mikawa K, Takao Y, Nishina K, Shiga M, Maekawa N, Obara H. Optimal
dose of granisetron for prophylaxis against postoperative emesis after
gynaecological surgery. Anesth Analg 1997;85:6526.
36. Domino KB, Anderson EA, Polissar NL, Posner KL. Comparative efficacy
and safety of ondansetron, droperidol, and metoclopramide for preventing
postoperative nausea and vomiting: a meta-analysis. Anesth Analg
1999;88:13709.
37. Fortney JT, Gan TJ, Graczyk S, Wetchler B, Melson T, Khalil S, et al.
A comparison of the efficacy, safety, and patient satisfaction of ondansetron
versus droperidol as antiemetics for elective outpatient surgical procedures:
S3A-409 and S3A-410 Study Groups. Anesth Analg 1998;86:7318.
38. Henzi I, Walder B, TramPr MR. Dexamethasone for the prevention of
postoperative nausea and vomiting: a quantitative systematic review. Anesth
Analg 2000;90:18694.
39. Liu K, Hsu CC, Chia YY. The effective dose of dexamethasone for
antiemesis after major gynecological surgery. Anesth Analg 1999;89:13168.
40. Wang JJ, Ho ST, Lee SC, Liu YC, Ho CM. The use of dexamethasone for
preventing postoperative nausea and vomiting in females undergoing
thyroidectomy: a dose-ranging study. Anesth Analg 2000;91:14047.
41. Wang JJ, Ho ST, Tzeng JI, Tang CS. The effect of timing of dexamethasone
administration on its efficacy as a prophylactic antiemetic for postoperative
nausea and vomiting. Anesth Analg 2000;91:1369.
42. Henzi I, Sonderegger J, Tramr MR. Efficacy, dose response, and adverse
effects of droperidol for prevention of postoperative nausea and vomiting.
Can J Anesth 2000;47:53751.
26. Turan A, Apfel CC, Kumpch M, Danzeisen O, Eberhart LH, Forst H, et al.
Does the efficacy of supplemental oxygen for the prevention of
postoperative nausea and vomiting depend on the measured outcome,
observational period or site of surgery? Anaesthesia 2006;61:62833.
27. Holte K, Klarskov B, Christensen DS, Lund C, Nielsen KG, Bie P, et al.
Liberal versus restrictive fluid administration to improve recovery after
laparoscopic cholecystectomy. Ann Surg 2004;240:8929.
46. Bailey PL, Streisand JB, Pace NL, Bubbers SJ, East KA, Mulder S, et al.
Transdermal scopolamine reduces nausea and vomiting after outpatient
laparoscopy. Anesthesiology 1990;72:97780.
30. Tramr MR, Reynolds DJM, Moore RA, McQuay HJ. Efficacy,
dose-response, and safety of ondansetron in prevention of postoperative
nausea and vomiting: a qualitative systematic review of randomized
placebo-controlled trials. Anesthesiology 1997;87:127789.
31. Sun R, Klein KW, White PF. The effect of timing of ondansetron
administration in outpatients undergoing otolaryngologic surgery. Anesth
Analg 1997;84:3316.
606
51. Lerman J. Surgical and patient factors involved in postoperative nausea and
vomiting. Br J Anaesth 1992;69:24S32S.
52. Kranke P, Morin AM, Roewer N, Wulf H, Eberhart LH. The efficacy and
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2002;95:13343.
64. Habib AS, El-Moalem HE, Gan TJ. The efficacy of the 5-HT3 receptor
antagonists combined with droperidol for PONV prophylaxis is similar to
their combination with dexamethasone. A meta-analysis of randomized
controlled trials. Can J Anesth 2004;51:31119.
65. Coloma M, White PF, Ogunnaike BO, Markowitz SD, Brown PM, Lee AQ,
et al. Comparison of acustimulation and ondansetron for the treatment of
established postoperative nausea and vomiting. Anesthesiology
2002;97:138792.
66. Ernst E, Pittler MH. Efficacy of ginger for nausea and vomiting:
a systematic review of randomized clinical trials. Br J Anaesth
2000;84:36771.
67. Hill RP, Soppitt AJ, Gan TJ. The effectiveness of rescue antiemetics in
patients who received a prophylactic antiemetic. Anesth Analg 2000;90:S8
(abstract).
68. Tramr M, Moore RA, Reynolds DJM, McQuay HJ. A quantitative systemic
review of ondansetron in treatment of established postoperative nausea and
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57. Brent R. The Bendectin Saga: another American tragedy (Brent 80);
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60. Diemuncsh PA, Apfel C, Phillip B, Gan TJ, Reiss TR. NK1 antagonist
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71. Gan TJ. Postoperative nausea and vomiting: Can it be eliminated? JAMA
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72. Polati E, Verlato G, Finco G, Mosaner W, Grosso S, Gottin L, et al.
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73. Gan TJ, Franiak R, Reeves J. Ondansetron orally disintegrating tablet versus
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