What Is the Best Strategy for Prevention of Postoperative Nausea and Vomiting?
Postoperative nausea and vomiting (PONV) are among the most common side effects associated with anesthesia and surgery. The overall incidence of PONV for all surgeries and patient populations is estimated to be 25% to 30%. PONV can lead to a delay in postanesthesia care unit discharge, unanticipated hospital admission, or both, thereby increasing medical costs. Symptoms of PONV are among the most unpleasant experiences associated with surgery and one of the most common reasons for poor patient satisfaction ratings in the postoperative period. Avoiding PONV is also an essential component of enhanced recovery after surgery (ERAS) programs. A number of risk factors have been identified and multiple interventions have been investigated for the prophylaxis against PONV. There are at least five major receptor systems involved in the pathogenesis of PONV: dopaminergic, cholinergic, histaminergic, serotonergic, and the neurokinin-1 receptors. Traditionally, antagonists at these receptors have been the mainstay of PONV management. In addition, other agents such as corticosteroids and propofol and nonpharmacologic techniques such as P6 stimulation have antiemetic properties. Because the etiology of PONV is multifactorial and there is evidence that combination antiemetic therapy is more effective than single-agent prophylaxis, a multimodal approach for the management of PONV should be adopted, including the use of a combination of antiemetic interventions coupled with strategies to reduce the baseline risk for PONV. Such strategies include the use of regional anesthesia, adequate hydration, total intravenous anesthesia with propofol, avoidance of volatile agents and nitrous oxide, and avoidance of high-dose neostigmine for neuromuscular block reversal.
