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Postoperative Nausea and Vomiting – Adult/Pediatric – Inpatient/Ambulatory

Postoperative Nausea and Vomiting – Adult/Pediatric – Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nausea and Vomiting


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Postoperative Nausea and Vomiting –
Adult/Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 4
METHODOLOGY ...................................................................................................................... 5
DEFINITIONS ............................................................................................................................ 6
INTRODUCTION ....................................................................................................................... 9
RECOMMENDATIONS .............................................................................................................10
UW HEALTH IMPLEMENTATION ............................................................................................15
REFERENCES .........................................................................................................................16
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2
CPG Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS- Manager, Drug Policy Program
Phone Number: 608-263-1328
Email Address: ptrapskin@uwhealth.org
CPG Contact for Content:
Name: Sara Shull, PharmD, MBA, BCPS- Analyst, Drug Policy Program
Phone Number: 608-262-1817
Email address: ssmith-shull@uwhealth.org
Guideline Authors:
Sara Shull, PharmD, MBA, BCPS
Chris Nemergut, PharmD
Tyler Liebenstein, PharmD
Coordinating Team Members:
Scott Springman, MD
Sara Shull, PharmD, MBA, BCPS
Review Individuals
Dianne Byerly, MD
Doug Coursin, MD
Megan Donovan, PharmD
Rhonda Gessler, MS, RN, ACNS-BC, CAPA
Elise Arsenault Knudsen, MS, RN, ACNS-BC
Elizabeth Laessig, MS, RN-BC
Jeffery Lee, MD
Jamie Limjoco, MD
Marissa Lowenthal, MD
Bridget Muldowney, MD
Jen Paquette, RN, BSN, CAPA
Peter Popic, MD
Deb Rusy, MD
Andrew Schroeder, MD
Ken Van Dyke, MD
Lana Volz, MD
Jessica Weber, MS, RN, ACNS-BC, CCTN
Sara Kroenke, BSN, RN
Committee Approvals/ Dates:
Perioperative Clinical Practices Committee: December 2015
Pharmacy and Therapeutics Committee: December 2015
Release Date: December 2015
Next Review Date: December 2018
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3
Executive Summary
Guideline Overview
Postoperative nausea and vomiting (PONV) is a common clinical problem that can be very
distressing to patients and potentially costly to manage. Unresolved PONV may result in
prolonged peri-anesthesia care and unanticipated hospital admissions. Systematic
assessment of the risk for PONV, implementation of prophylaxis in “at risk” patients with an
appropriate anti-emetic(s), and routine monitoring of PONV can minimize negative outcomes
and increase patient satisfaction.1 The purpose of the guideline is to facilitate effective
management of PONV in adult and pediatric patients. Neonates (including patients residing in
the NICU) are not within the scope of this guideline and recommendations for management are
not included.
Key Practice Recommendations
1. Prior to surgery, all surgical patients should be assessed for risk factors for PONV and a
score assigned score which indicates probability of PONV. Class 1 Level A
2. Modifiable risk factors should be minimized before and during surgery when possible.
Class 1 Level A
3. Appropriate prophylactic medication(s) should be ordered and administered as
warranted by risk score (low, moderate, or high risk). Class 1 Level A
4. When PONV occurs despite prophylaxis, or when no prophylaxis has been
administered, select appropriate rescue medication to minimize negative outcomes.
Class 1 Level A
5. When PONV does not respond to rescue medication(s), physical factors or
administration of emetogenic medications should also be evaluated. Class 1 Level A
6. Actively monitor efficacy of prophylactic and/or rescue treatment with the nausea visual
analogue scale (0-10 scale). Consider administration of rescue medication when patient
indicates nausea severity ranks “four or above” on a 0- 10 scale. Class 1 Level B
Companion Documents
1. Post-operative nausea and vomiting scale
Pertinent UW Health Policies & Procedures
There are no related policies or procedures.
Patient Resources
There are no related patient resources.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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4
Scope
The guideline provides recommendations for PONV risk assessment, preventing PONV,
managing rescue therapy and monitoring success with prophylactic or rescue therapy. Dose
and administration frequency are provided for commonly used prophylactic and rescue
medications.
Intended Users:
This guideline is intended to be used by physicians, advanced practice providers, registered
nurses, and pharmacists involved in the care of surgical patients that are at risk for or
experiencing PONV.
Target Population:
The targeted populations are adult and pediatric patients at risk for PONV and post-discharge
nausea and vomiting (PDNV) undergoing inpatient or ambulatory surgery. Recommendations
for management of the neonatal (including patients residing in the NICU) population are not
included.
Interventions and Practices Considered:
This guideline focuses on assessment of the risk for PONV in surgical patients, the minimization
of modifiable risk factors and selection of pharmacologic prophylaxis of PONV, effective
treatment of established PONV, and a tool for monitoring success of PONV management.
Major Outcomes Considered:
Surgical patients who receive appropriate PONV prophylaxis and rescue treatment should avoid
symptoms or experience significant improvement in clinical symptoms of nausea and vomiting
measured according to a visual analogue scale with a goal of less than four on a 0-10 scale.
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5
Methodology
A literature search was performed in the PubMed database with search terms “post-operative
nausea and vomiting”, “post-operative nausea and vomiting – pediatrics” and “post-discharge
nausea and vomiting”. Articles were included if they provided information on PONV risk
assessment, appropriate risk modification, pharmacologic prophylaxis and rescue, and PONV
monitoring.
A modified Grading of Recommendations Assessment, Development and Evaluation (GRADE)
developed by the American Heart Association and American College of Cardiology (Figure 1)
were used to assess the quality and strength of the evidence in this clinical practice guideline.2
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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6
Definitions
1. Post-operative nausea and vomiting (PONV): an unpleasant complication of general
anesthesia, emetogenic medications, or physical/metabolic changes occurring within 24
hours after surgery/ procedures.
2. Post-operative vomiting (POV): vomiting occurring after surgery in pediatric patients.
Children may have less ability to verbalize the experience of nausea.
3. Post-discharge nausea and vomiting (PDNV): PONV which persists after discharge and
continues in the ambulatory setting
4. Risk Factors for PONV3-5
4.1. History of motion sickness
4.2. Previous PONV
4.3. Female gender
4.4. Nonsmoking
4.5. Younger age (<50 years)
4.6. General anesthesia
4.6.1. Local or regional anesthesia reduces the risk of PONV when used as the
primary anesthetic and/ or post-operatively to reduce use of opioid medications.
4.7. Use of volatile anesthetics and nitrous oxide4,5
4.7.1. Use of propofol may reduce risk of PONV when used for both induction and
maintenance of anesthesia and the baseline risk is at least 40%.6
4.8. Intraoperative and postoperative use of opioid medications
4.9. Duration of anesthesia
4.9.1. Each 30 minute increase in surgery duration increases PONV incidence by 60%.
4.10. Type of surgery7
4.10.1. Higher risk of PONV is associated with cholecystectomy, laparoscopic surgery,
gynecologic surgery, major breast surgery, head & neck surgeries including
plastic procedures, neurosurgery, and strabismus repair
4.11. Dehydration
5. Factors to consider in managing PONV/POV/PNDV:
5.1. Potential morbidity associated with PONV (increased intracranial pressure, suture
dehiscence, incisional hernia, esophageal rupture, hematoma, aspiration pneumonitis)
5.2. Patient comfort
5.3. Patient concern and attitude regarding PONV
5.4. Concurrent illness
5.5. Outpatient versus inpatient pathway including time of day for outpatient discharge
5.6. Cost of medications and medical care
5.7. Efficacy of antiemetics
5.7.1. Consider anti-nausea effect versus anti-vomiting effect1
5.7.2. Ondansetron is more effective at reducing vomiting than nausea
5.7.3. Propofol is more effective at reducing nausea than vomiting
5.8. Adverse effects of antiemetics
5.9. Concomitant opioid medication requirements
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7
6. Simplified risk scoring for PONV/POV/PDNV
6.1. In adults, a useful model for predicting PONV integrates four primary risk factors:3
6.1.1. female gender
6.1.2. nonsmoker
6.1.3. postoperative opioid use and/or volatile anesthesia
6.1.4. previous history of PONV and/or motion sickness
6.2. As the number of risk factors increase, the associated risk of PONV increases. When
none, one, two, three, or four of these factors are present, the associated risk of PONV
is approximately 10%, 20%, 40%, 60%, and 80%, respectively (Figure 2).
6.3. Patients with 0-1, 2, or 3-4 risk factors are considered to be at “low”, “moderate”, and
“high” risk respectively.1
Figure 2. Simplified PONV risk score in adults
Risk Factors (RF) Points
Female Gender 1
Nonsmoker 1
Postoperative opioids / Volatile
anesthetics
1
History of PONV / Motion
sickness
1
Sum 0-4
0%
20%
40%
60%
80%
100%
0 1 2 3 4
10%
20%
40%
60%
80%
P
O
N
V
R
i
s
k
Risk Score
Moderate High Low
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8
6.4. In children, four primary independent risk factors for POV are integrated:
6.4.1. duration of surgery more than 30 minutes
6.4.2. age ≥ 3 years
6.4.3. strabismus surgery
6.4.4. positive history of POV in the patient, parent, or sibling8
6.5. As the number of risk factors increase, the associated risk of POV increases. When
none, one, two, three or four of these factors are present, the associated risk of POV is
approximately 10%, 10%, 30%, 55%, and 70%, respectively (Figure 3)
Figure 3. Simplified POV risk score in children
Risk Factors (RF) Points
Surgery ≥ 30 minutes 1
Age ≥ 3 years 1
Strabismus surgery 1
History of POV/PONV in patient
or relatives
1
Sum 0-4
0%
20%
40%
60%
80%
100%
0 1 2 3 4
10% 10%
30%
55%
70%
P
O
V
R
i
s
k
Risk Score
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9
6.5 In adult patients undergoing outpatient surgeries, five independent risk factors are
integrated to predict the risk of post-discharge nausea and vomiting (PDNV) in adults are
6.5.1 female sex
6.5.2 history of PONV
6.5.3 age <50 years
6.5.4 use of opioids in the PACU
6.5.5 nausea in the PACU.9
6.6 As the number of risk factors increase, the associated risk of PDNV increases. When
zero, one, two, three, four, or five of these factors are present, the associated risk of
PDNV is approximately 10%, 20%, 30%, 50%, 60% and 80%, respectively. (See Figure
4)
Figure 4. Simplified PDNV risk score in adults
Risk Factors (RF) Points
Female Gender 1
History of PONV 1
Age <50 years 1
Use of opioids in the PACU 1
Nausea in the PACU 1
Sum 0-5
Introduction
Postoperative nausea and vomiting occurs, on average, in 25% to 30% of patients who have
undergone surgery, although the incidence may increase to 70% to 80% after high-risk
procedures or in high-risk patients.10 Assessment of the risk for PONV is made based on
patient factors, type of surgery, and type of anesthesia. When clinically indicated, the baseline
risk may be reduced by pharmacologic and non-pharmacologic means, including minimization
of modifiable risk factors.1 Prophylaxis of PONV in adults and POV in children should be
considered when patients are at a moderate-to-high risk. Prophylaxis should also be
considered for patients at low risk for PONV but who would experience adverse sequelae if they
vomited. The effectiveness of available prophylactic medications is largely dependent on the
dose and timing of administration. Treatment of PONV should be initiated only after medical
causes of nausea are ruled out, such as increased intracranial or intraocular pressure, GI tract
obstruction, hypoglycemia, hyponatremia, or other metabolic abnormalities. Intractable PONV
should be treated to decrease the incidence of postoperative sequelae and to enhance patient
comfort. Post discharge nausea and vomiting (PDNV) occurs in approximately 35% of
0%
20%
40%
60%
80%
100%
0 1 2 3 4 5
10%
20%
30%
50%
60%
80% P
D
N
V
R
i
s
k
Risk Score
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10
ambulatory surgery patients, most of whom had not experienced nausea or vomiting in the
recovery room.11 Patients who experience PDNV have substantial distress and impairment as a
result and may not have immediate access to treatment. The administration of prophylactic
antiemetics is warranted in patients at risk for PDNV.
Recommendations
Prophylaxis:
1. Mitigate baseline risk factors, if possible. (Class I, Level C)
1.1. Use local or regional anesthesia in preference to general anesthesia whenever
possible.12 (Class I, Level A)
1.2. Consider total IV anesthesia (TIVA) by using propofol for induction and maintenance.6
(Class I, Level A)
1.3. If possible, avoid volatile anesthetics and nitrous oxide4,5,13-15 (Class I, Level A)
1.4. If possible, minimize intraoperative and postoperative opioids3,16-18 (Class I, Level A)
1.4.1. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be considered in lieu of
opioid analgesics or as multi-modal opioid sparing agents in appropriate patients
when considering analgesic goals and risk factors for adverse effects19-21 (Class
I, Level A)
2. Maintain physiologic homeostasis
2.1. Adequate hydration of all patients with appropriate IV fluid is recommended22-24 (Class
I, Level A)
2.2. Management of hypotension, bradycardia (atropine, ephedrine), hyperglycemia, and
other abnormal physiologic measures should be optimized. (Class I, Level C)
2.3. Avoid abrupt changes in body/head position, especially to the upright position (Class I,
Level C)
3. Providers should consider a variety of individualized/ patient centered measures to minimize
PONV or provide prophylaxis.
3.1. Preoperative liquid oral carbohydrate intake may decrease PONV and is reasonable to
consider.25 (Class IIb, Level B)
3.2. Every patient should be assessed for risk factors and a risk score estimated to
determine need for pharmacologic prophylaxis. See figures 2, 3, 4.26 (Class I, Level A)
3.3. All pharmacologic anti-emetics have approximately the same efficacy: a reduction of 20-
25% in the risk of PONV from the pre-treatment risk.6 When pharmacologic prophylaxis
is warranted, consider the level of PONV risk, patient specific pre-existing conditions,
type of surgery and anesthesia exposure, cost efficiency, and the most efficacious
drug(s) with the fewest adverse effects.1 (Class 1, Level A)
3.3.1. Low risk: Omitting pharmacologic prophylaxis may be considered to avoid
adverse effects unless there is a risk due to adverse sequelae of vomiting (e.g.
increased intracranial pressure, wired jaws, post gastric/ esophageal surgery).1
(Class I, Level C)
3.3.2. Moderate risk: Use two medications from different therapeutic classes.
3.3.2.1. Adults - Use two agents. Recommended agents include: ondansetron,
dexamethasone, promethazine, prochlorperazine, diphenhydramine,
haloperidol, meclizine, and scopolamine.6 (Class 1, Level A)
3.3.2.2. Pediatric patients should receive at least two agents, including
ondansetron.27-29 (Class I, Level A)
3.3.2.3. A recommended combination for both adult and pediatric populations is
dexamethasone plus ondansetron.30-33 (Class I, Level A)
3.3.3. High risk: Use a combination of three agents with differing receptor sites of
action for a multi-modal approach. Combinations include midazolam +
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11
dexamethasone; dexamethasone + ondansetron; and haloperidol +
dexamethasone. Each combination is added to another antiemetic. (Class 1
Level A)
3.4. Aprepitant failed to show superiority to ondansetron in achieving a complete response
at 24 hours after surgery when preventing PONV in two head-to-head randomized,
double-blind trials.34,35 Use of aprepitant did result in better outcomes than ondansetron
between 24 – 48 hours. However, due to limited clinical experience and unknown role
in routine prophylaxis36 along with high cost ($77/ 40 mg) relative to alternatives , the
use of aprepitant remains formulary restricted to the Oncology, Hematology, or BMT
services for use in patients receiving chemotherapy agents. (Class III, Level A)
3.5. Oral olanzapine has been shown to be more efficacious than placebo, and no different
than ondansetron for the prevention of nausea and vomiting in patients undergoing
breast surgeries.37 Olanzapine may be considered for PONV prophylaxis in this
population. (Class IIa, Level B)
3.6. When patients have a significant history of motion sickness-related nausea or are
having middle ear surgery, consider meclizine (25-50 mg by mouth), diphenhydramine
(5-10 mg intravenously), or scopolamine (1.5 mg transdermal patch or 400 mcg tablet
by mouth). (Class IIb, Level C)
3.7. Stimulation of the wrist acupuncture point P6 is more effective than a sham in
preventing PONV when used independently of pharmacologic anti-emetics.38 However,
they provide no better PONV prophylaxis than pooled anti-emetics but at greater cost.
Pressure bands (Seabands, ReliefBands)39 as adjunctive therapy to ondansetron are no
more effective than ondansetron administered alone. Therefore the bands are not
recommended. (Class III, Level B)
3.8. Ginger (1 gram orally), as an adjunct to prophylactic anti-emetic therapy may improve
outcomes when administered one hour prior to anesthetic induction. Evidence of
prophylactic efficacy is conflicting.40-44 Administration may be considered as outcomes
are no worse with ginger, adverse effects are minimal, and cost is low. (Class IIb, Level
A)
3.9. Administration of midazolam 2mg IV X1 30 minutes prior to the end of surgery may be
considered.45 (Class IIb, Level B)
3.10. Oral liquids may be initiated after anesthetic emergence in many patients, when
appropriate. Liquids should be at room temperature, or slightly warmed to body
temperature. Cold liquids should not be administered as they slow gastric emptying
and increase risk of vomiting.46-49 (Class III, Level B)
3.11. Administration of supplemental oxygen does not reduce the risk of PONV and is not
recommended.50 (Class III, Level A)
3.12. The following tactics are also not recommended for PONV prophylaxis because they
have been determined to be ineffective: music therapy51, isopropyl alcohol inhalation52,
intraoperative gastric decompression53, proton pump inhibitors54,55, administration of a
nicotine patch to non-smokers56,57, hypnosis58, cannabinoids59,60, intraoperative
supplemental oxygen50, and therapeutic suggestions via earphones while anesthetized.
61
. (Class III, Level B)
Rescue/ treatment:
1. It may be reasonable to forego treating a single episode of emesis if the patient has no
further nausea/ vomiting. (Class IIb, Level C)
1.1. However, if the timing of emesis is late in the day for outpatients, the risk of admission
is higher and treatment should be considered.62-64 (Class I, Level A)
2. In persistent nausea and vomiting, physical factors or emetogenic medications should be
ruled out before initiation of antiemetics.
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12
2.1. Consider postoperative migraine headache, increased intracranial pressure,
gastrointestinal ileus, blood accumulation in the stomach, inadequate hydration, and
hypotension as causes of nausea and vomiting and intervene where necessary. Also
consider emetogenic medications such as postoperative opiates as a source of
persistent nausea and vomiting. Eliminate or minimize opioid doses if possible.1 (Class
I, Level C)
3. Providers should consider a variety of individualized/ patient centered measures when
selecting rescue therapy
3.1. If the patient has received no prophylaxis, treatment with a 5HT3 antagonist
(ondansetron) is recommended.65,66 (Class I, Level B)
3.2. If PONV occurs despite recommended prophylaxis, use a medication from another
class for rescue treatment.67 (Class I, Level B)
3.2.1. Treat with ondansetron if dexamethasone was the prophylactic antiemetic used;
if dexamethasone and a 5-HT3 antagonist were used in combination, select an
agent from another class, such as haloperidol or promethazine.
3.2.2. Propofol can also be used at a dose of 20mg as needed.68-70 (Class I, Level A)
3.2.3. If a 5-HT3 antagonist was used for prophylaxis, do not use another medication
from this class within 6 hours after administration71,72 (Class III, Level B)
3.3. When dizziness is present, consider anti-motion sickness therapy (e.g. meclizine or
diphenhydramine), as long as dizziness is not induced by hypotension. (Class I, Level
C)
3.4. When nausea and vomiting are related to orthostatic hypotension, consider additional
IV fluids and check for surgical bleeding. Consider giving ephedrine (25-50mg IM or 10-
20 mg IV, slowly), especially in young females. Consider atropine (0.4-1 mg) for
vasovagal bradycardia, especially in young adult males. (Class I, Level C)
3.5. Low dose naloxone infusion (0.25mcg/kg/hr) ) may be considered for management of
nausea in appropriate patients with opioid related nausea.73 (Class I, Level B)
3.6. Aroma therapy with volatile essential oils or isopropyl alcohol may be beneficial as
adjunct therapy to rescue anti-emetics in the short term alleviation of breakthrough
nausea. Aroma therapy may decrease the need for other rescue anti-emetic therapy.
These products may be considered for nauseated patients in the PACU.74-78 (Class IIb,
Level A)
3.7. There is no evidence that deep breathing, compresses applied to the forehead, or
repositioning are effective in the prevention or treatment of PONV and they are not
recommended as alternatives to rescue anti-emetics. However, these tactics present
minimal risk and no cost and so may be considered as adjunct therapy to antiemetic
medications.1 (Class IIb, Level C)
Ambulatory Surgery and PDNV
1. Mixing routes of anti-emetic administration, IV and PO, can be beneficial. (e.g. IV
dexamethasone + oral ondansetron).1 (Class IIa, Level B)
2. Combining anti-emetic medications from varied therapeutic classes is reasonable. (Class
IIa, Level B)
3. Patients at high risk for PDNV may benefit from an appropriate outpatient prescription of
antiemetic therapy.62,63 (Class I, Level A)
4. Recommended antiemetics include:
4.1. Scopolamine transdermal patch, which is most effective if placed pre-operatively79
(Class I, Level B)
4.2. Ondansetron orally disintegrating tablets80 (Class I, Level B)
4.3. Prochlorperazine tablets or suppositories (Class IIa, Level C)
4.4. Olanzapine orally disintegrating tablets. (Class IIa, Level C)
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13
5. Management of PDNV should be included in educational materials provided to the patient at
discharge. (Class I, Level C)
Monitoring
1. Patients should be assessed for the presence and severity of nausea and vomiting to
determine the need to administer a rescue anti-emetic.81 (Class 1, Level C)
1.1. Assessment should occur at minimum when patients enter and leave the PACU, or
after administration of a rescue anti-emetic.81 (Class I, Level C)
1.2. A visual analogue scale (VAS), or other discreet scale, should be used to quantify the
presence or severity of nausea/ vomiting.81,82 (Class I, Level B)
1.2.1. A rescue antiemetic should be administered when the patient indicates the
severity of nausea ranks at ≥4, as measured on a 0 – 10 scale.82 (Class I, Level B)
ξ 0 (zero) = no nausea
ξ 1-3 = mild nausea
ξ 4-7 = moderate nausea
ξ 8-10 = severe nausea
2. A rescue antiemetic may be considered when requested by the patient regardless of nausea
severity (e.g. mild nausea) to promote patient satisfaction. (Class IIb, Level C)
3. It is reasonable to assess post-surgical patients housed on inpatient units for the presence
and/or severity of PONV according to the VAS scale at least once in an 8 hour period for the
first 24 hours following the end of surgery. (Class IIa, Level C)
4. The overall success of strategies implemented to improve management of PONV should be
routinely measured. (Class I, Level C)
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14
UWHC Formulary Antiemetic Agents Used in PONV83-85
Table 1. Antiemetics
Medication Site of Action
Therapeutic
Goal Dose*
Adverse Effects (rare events
w/ minimal doses are not
listed)
Approximate
Cost per Dose
Dexamethasone Unknown Prophylaxis
Adult: 4-6 mg IV after induction (or very slowly IV before induction)
Pediatric: 0.15 mg/kg (max = 5 mg) IV after induction
Do not re-dose for rescue
Burning perineal/rectal pain when
given rapidly IV $1.50
Diphenhydramine H1, M1 Prophylaxis &
rescue
Adult: 10-50 mg IM/IV every 3 hr or 25-50 mg PO every 6 hr (max = 400 mg daily)
Pediatric: 0.5-1 mg/kg IM/IV/PO in 4 divided doses (max = 6 doses daily) Sedation, dry mouth
< $1.00 (oral and
IV)
Haloperidol D2 Prophylaxis Adult: 0.5-2 mg IM/IV at the start or end of surgery Pediatric: 0.01 mg/kg IV following induction
Sedation, hypotension, EPS,
tachycardia, neuroleptic syndrome,
QT prolongation/torsade de pointes
< $1.00
Meclizine H1 Prophylaxis &
rescue
Adult: 25 – 50 mg PO prior to induction
Pediatric: (> 12yo): 25 – 50 mg PO prior to induction
Drowsiness, fatigue, headache,
xerostomia, vomiting, blurred vision < $1.00
Metoclopramide D2 Prophylaxis Adult: 10-20 mg IV and every 6 hrs prn Pediatric: 0.1 – 0.5 mg/kg at induction or arrival in PACU (max dose = 10 mg)
Sedation, diarrhea, EPS,
hypotension, SVT, bradycardia,
neuroleptic malignant syndrome
< $2.00
Olanzapine 5-HT2,D2, H1 Prophylaxis Adult: 10 mg PO once prior to induction Drowsiness
< $2.00 (orally
disintegrating tab)
Ondansetron 5-HT3, Prophylaxis &
rescue
Adult: 4 mg IV at the end of surgery
Pediatric: for weight < 40 kg: 0.1 mg/kg IV; for weight ≥ 40 kg: 4 mg IV at the end of
surgery. Wait at least 6 hours before re-dosing for rescue71
Headache, constipation, QT
prolongation with high doses
< $1.00 (IV and
orally
disintegrating tab)
Prochlorperazine D2 Prophylaxis &
rescue
Adult: 5-10 mg IM 1-2 hrs before induction; 5-10 mg IV at end of surgery (< 1 mg/min); 5-
10 mg IV/PO PRN every 6 hr; or 25 mg PR twice daily
Pediatric (>2yo & wgt ≥ 9 kg)**: 0.1-0.15 mg/kg IM, IV every 8-12 hr PRN (max dose =
10mg)
Psychosis, sedation, hallucinations,
EPS
$11.00 (IV)
<$1.00 (oral)
Promethazine D2, H1, M1
Prophylaxis &
rescue
Adult: 12.5–25 mg IV, IM, PO or PR at induction or every 6 hrs prn
Pediatric (> 2yo)** 0.25 - 1 mg/kg IV, IM, PO or PR every 4-6 hr prn (max dose = 25mg) EPS, hallucinations, sedation, pain on
injection, extravasation, necrosis
<$1.00 (IV and
oral)
$10.00
(suppository)
Scopolamine M1 Prophylaxis Adult: 1.5 mg TD patch applied before surgery Pediatric (≥ 12 yo): 1.5 mg TD patch applied before surgery
Tachycardia, hypotension, psychosis,
dry mouth, urinary retention,
restlessness, sedation, amnesia
$20.00
*pediatric doses should not exceed adult doses ** reserved for those who have failed all other therapies and are admitted to the hospital – contraindicated in children ≤ 2 years; IM=intramuscularly;
IV=intravenously; PO=orally; PR=rectally; TD=transdermal; inj=injection; tab=tablet; supp=suppository; cap=capsule; susp=suspension; amp=ampule; D2=dopamine type 2 receptor; H1=histamine type 1
receptor; M1=muscarinic cholinergic type 1 receptor; NK1= neurokinin 1 receptor; 5-HT2=serotonin type 2 receptor; 5-HT3=serotonin type 3 receptor
NOTE: Individual antiemetic medications generally reduce pre-treatment risk by 20 – 25%.6 Adding a second antiemetic from another class reduces post-treatment risk by another 20-25%. It is not
possible to eliminate the risk of PONV even with 3 or 4 anti-emetics.
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15
UW Health Implementation
Benefits/Harms of Implementation
1. Adoption of a standardized approach to eliminate PONV or minimize its severity increases
the likelihood that patients will remain comfortable and satisfied after surgery.
2. Recovery time after surgery may be attenuated.
3. Patients may experience adverse effects to medications use to prevent or treat PONV.
These include but are not limited to headache, dizziness, sedation, muscular pain,
hypotension, dysphoria, extra-pyramidal symptoms, and increased nausea.
Qualifying Statements
The recommendations for assessing risk for PONV, selecting appropriate prophylaxis or
treatment, and monitoring are based on the best available literature. When evidence derived
from meta-analyses, randomized controlled or uncontrolled clinical trials, observational studies,
or case reports is not available, expert consensus statements are included.
Implementation Plan/Tools
1. The guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management Corner
within the Best Practice newsletter.
3. Links to this guideline will be updated and/or added in Health Link and Lexicomp.
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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16
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2015CCKM@uwhealth.org