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Clinical Reviews |
JULIE GOLEMBIEWSKI, PHARM.D., is Clinical Associate Professor, Departments of Pharmacy Practice and Anesthesiology, University of Illinois at Chicago. ERIC CHERNIN, B.S.PHARM., is Pharmaceutical Care Specialist—Operating Room Pharmacy, Department of Pharmaceutical Care Services, Sarasota Memorial Hospital, Sarasota, FL. TANIA CHOPRA, PHARM.D., is Formulary Manager, Department of Pharmaceutical Services, San Francisco General Hospital, San Francisco, CA.
Address correspondence to Dr. Golembiewski at the Department of Pharmacy Practice (MC 886), College of Pharmacy, University of Illinois at Chicago, 833 S. Wood Street, Room 164, Chicago, IL 60612-7230 (jgolemb{at}uic.edu).
Summary. Factors to consider when determining a patient’s risk for PONV include sex, history of PONV, history of motion sickness, smoking status, duration of anesthesia, use of opioids, and type of surgery. Receptors that, when activated, can cause nausea or vomiting or both include dopamine type 2, serotonin type 3, histamine type 1, and muscarinic cholinergic type 1 receptors. Patients at moderate to high risk for PONV benefit from the administration of a prophylactic antiemetic agent that blocks one or more of these receptors. Effective agents include transdermal scopolamine, prochlorperazine, promethazine, droperidol, ondansetron, dolasetron, granisetron, and dexamethasone. In high-risk patients, combining two or more antiemetics with different mechanisms of action has been shown to be more effective than using a single agent. In addition to administering a prophylactic antiemetic, it is important to reduce the patient’s risk by considering regional anesthesia, considering inducing and maintaining general anesthesia with propofol, ensuring good intravenous hydration, avoiding hypotension, and providing effective analgesia. If PONV occurs in the immediate postoperative period, it is best treated with an antiemetic agent from a pharmacologic class different from that of the prophylactic agent.
Conclusion. Prophylactic antiemetic therapy for PONV is effective, but combinations of agents may be necessary for high-risk patients. Nonpharmacologic strategies are also important.
Index terms: Anesthetics; Antiemetics; Combined therapy; Dexamethasone; Dolasetron; Droperidol; Granisetron; Mechanism of action; Ondansetron; Opiates; Patches transdermal; Postoperative nausea and vomiting; Prochlorperazine; Promethazine; Propofol; Scopolamine; Steroids cortico-; Toxicity
Purpose. The physiology, risk factors, and prevention and treatment of postoperative nausea and vomiting (PONV) are discussed.
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