Table 1.
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Risk Factors Associated With the Development of PONV and PDNVa,2,24

Factors with Strong Supporting EvidenceFactors with Weak Supporting Evidence
a”Strong evidence” is supported by multiple randomized trials or meta-analysis evaluating multiple (3–5) populations with general consistency of direction and magnitude of effect. “Weak evidence” is supported by single randomized trials or nonrandomized studies evaluating limited (2–3) populations.

  • Female gender

  • History of motion sickness

  • Nonsmoker

  • History of PONV

  • Postoperative use/administration of opioids

  • Use of volatile anesthetics

  • Use of nitrous oxide

  • Younger age

  • Type of procedure

    • –Laparoscopy

    • –Laparotomy GYN surgery

    • –Breast surgery

    • –Craniotomy

    • –ENT surgery

  • Type of anesthesia

    • –Mask ventilation

    • –Long duration of anesthesia >1 hr

Factors with Strong Supporting EvidenceFactors with Weak Supporting Evidence
a”Strong evidence” is supported by multiple randomized trials or meta-analysis evaluating multiple (3–5) populations with general consistency of direction and magnitude of effect. “Weak evidence” is supported by single randomized trials or nonrandomized studies evaluating limited (2–3) populations.

  • Female gender

  • History of motion sickness

  • Nonsmoker

  • History of PONV

  • Postoperative use/administration of opioids

  • Use of volatile anesthetics

  • Use of nitrous oxide

  • Younger age

  • Type of procedure

    • –Laparoscopy

    • –Laparotomy GYN surgery

    • –Breast surgery

    • –Craniotomy

    • –ENT surgery

  • Type of anesthesia

    • –Mask ventilation

    • –Long duration of anesthesia >1 hr

Table 1.
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Risk Factors Associated With the Development of PONV and PDNVa,2,24

Factors with Strong Supporting EvidenceFactors with Weak Supporting Evidence
a”Strong evidence” is supported by multiple randomized trials or meta-analysis evaluating multiple (3–5) populations with general consistency of direction and magnitude of effect. “Weak evidence” is supported by single randomized trials or nonrandomized studies evaluating limited (2–3) populations.

  • Female gender

  • History of motion sickness

  • Nonsmoker

  • History of PONV

  • Postoperative use/administration of opioids

  • Use of volatile anesthetics

  • Use of nitrous oxide

  • Younger age

  • Type of procedure

    • –Laparoscopy

    • –Laparotomy GYN surgery

    • –Breast surgery

    • –Craniotomy

    • –ENT surgery

  • Type of anesthesia

    • –Mask ventilation

    • –Long duration of anesthesia >1 hr

Factors with Strong Supporting EvidenceFactors with Weak Supporting Evidence
a”Strong evidence” is supported by multiple randomized trials or meta-analysis evaluating multiple (3–5) populations with general consistency of direction and magnitude of effect. “Weak evidence” is supported by single randomized trials or nonrandomized studies evaluating limited (2–3) populations.

  • Female gender

  • History of motion sickness

  • Nonsmoker

  • History of PONV

  • Postoperative use/administration of opioids

  • Use of volatile anesthetics

  • Use of nitrous oxide

  • Younger age

  • Type of procedure

    • –Laparoscopy

    • –Laparotomy GYN surgery

    • –Breast surgery

    • –Craniotomy

    • –ENT surgery

  • Type of anesthesia

    • –Mask ventilation

    • –Long duration of anesthesia >1 hr

Table 2.
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Neurotransmitters Involved in Emesis That Are Targeted by Some Current Therapies22,23,24

SiteReceptorNeurotransmitterAntagonist
Vomiting Center5-HT3 receptorSerotonin5-HT3 antagonist
NK-1 receptorSubstance PAprepitant
Dopamine receptorDopamineMetoclopramide
Chemoreceptor Trigger Zone5-HT3 receptorSerotonin5-HT3 antagonist
NK-1 receptorSubstance PAprepitant
Dopamine receptorDopamineMetoclopramide
Gastrointestinal Tract5-HT3 receptorSerotonin5-HT3 antagonist
BrainBenzodiazepine receptorLorazepam
SiteReceptorNeurotransmitterAntagonist
Vomiting Center5-HT3 receptorSerotonin5-HT3 antagonist
NK-1 receptorSubstance PAprepitant
Dopamine receptorDopamineMetoclopramide
Chemoreceptor Trigger Zone5-HT3 receptorSerotonin5-HT3 antagonist
NK-1 receptorSubstance PAprepitant
Dopamine receptorDopamineMetoclopramide
Gastrointestinal Tract5-HT3 receptorSerotonin5-HT3 antagonist
BrainBenzodiazepine receptorLorazepam
Table 2.
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Neurotransmitters Involved in Emesis That Are Targeted by Some Current Therapies22,23,24

SiteReceptorNeurotransmitterAntagonist
Vomiting Center5-HT3 receptorSerotonin5-HT3 antagonist
NK-1 receptorSubstance PAprepitant
Dopamine receptorDopamineMetoclopramide
Chemoreceptor Trigger Zone5-HT3 receptorSerotonin5-HT3 antagonist
NK-1 receptorSubstance PAprepitant
Dopamine receptorDopamineMetoclopramide
Gastrointestinal Tract5-HT3 receptorSerotonin5-HT3 antagonist
BrainBenzodiazepine receptorLorazepam
SiteReceptorNeurotransmitterAntagonist
Vomiting Center5-HT3 receptorSerotonin5-HT3 antagonist
NK-1 receptorSubstance PAprepitant
Dopamine receptorDopamineMetoclopramide
Chemoreceptor Trigger Zone5-HT3 receptorSerotonin5-HT3 antagonist
NK-1 receptorSubstance PAprepitant
Dopamine receptorDopamineMetoclopramide
Gastrointestinal Tract5-HT3 receptorSerotonin5-HT3 antagonist
BrainBenzodiazepine receptorLorazepam
Table 3.
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Baseline Characteristics of Participants in the POSTOP Study27

Demographic characteristicsn= 376
Mean age, years (range)42 (19–86)
Female, n (%)343 (91)
No history of smoking, n (%)257 (68)
History of PONV, n (%)161 (43)
History of motion sickness, n (%)178 (47)
Type of surgery,n(%)n= 376
Laparoscopic procedures313 (83)
    Abdominal surgery175 (47)
    Gynecological surgery138 (37)
Major plastic surgery63 (17)
Demographic characteristicsn= 376
Mean age, years (range)42 (19–86)
Female, n (%)343 (91)
No history of smoking, n (%)257 (68)
History of PONV, n (%)161 (43)
History of motion sickness, n (%)178 (47)
Type of surgery,n(%)n= 376
Laparoscopic procedures313 (83)
    Abdominal surgery175 (47)
    Gynecological surgery138 (37)
Major plastic surgery63 (17)
Table 3.
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Baseline Characteristics of Participants in the POSTOP Study27

Demographic characteristicsn= 376
Mean age, years (range)42 (19–86)
Female, n (%)343 (91)
No history of smoking, n (%)257 (68)
History of PONV, n (%)161 (43)
History of motion sickness, n (%)178 (47)
Type of surgery,n(%)n= 376
Laparoscopic procedures313 (83)
    Abdominal surgery175 (47)
    Gynecological surgery138 (37)
Major plastic surgery63 (17)
Demographic characteristicsn= 376
Mean age, years (range)42 (19–86)
Female, n (%)343 (91)
No history of smoking, n (%)257 (68)
History of PONV, n (%)161 (43)
History of motion sickness, n (%)178 (47)
Type of surgery,n(%)n= 376
Laparoscopic procedures313 (83)
    Abdominal surgery175 (47)
    Gynecological surgery138 (37)
Major plastic surgery63 (17)
Table 4.
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Patterns of Antiemetic Agents Used During the POSTOP Study.27 Reprinted with permission from reference 27.

Antiemetics used prophylacticallyPercentage used (n= 376)
None8
Single agent34
    5-HT325
    Metoclopramide5
    Dexamethasone4
    Droperidol<1
Two-drug combinations (%)35
    5-HT3 + dexamethasone21
    5-HT3 + other11
    Non 5-HT3 with a non 5-HT33
Combinations of 3 or more drugs23
    5-HT3 + dexamethasone + droperidol9
    5-HT3 + dexamethasone + other14
Antiemetics used prophylacticallyPercentage used (n= 376)
None8
Single agent34
    5-HT325
    Metoclopramide5
    Dexamethasone4
    Droperidol<1
Two-drug combinations (%)35
    5-HT3 + dexamethasone21
    5-HT3 + other11
    Non 5-HT3 with a non 5-HT33
Combinations of 3 or more drugs23
    5-HT3 + dexamethasone + droperidol9
    5-HT3 + dexamethasone + other14
Table 4.
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Patterns of Antiemetic Agents Used During the POSTOP Study.27 Reprinted with permission from reference 27.

Antiemetics used prophylacticallyPercentage used (n= 376)
None8
Single agent34
    5-HT325
    Metoclopramide5
    Dexamethasone4
    Droperidol<1
Two-drug combinations (%)35
    5-HT3 + dexamethasone21
    5-HT3 + other11
    Non 5-HT3 with a non 5-HT33
Combinations of 3 or more drugs23
    5-HT3 + dexamethasone + droperidol9
    5-HT3 + dexamethasone + other14
Antiemetics used prophylacticallyPercentage used (n= 376)
None8
Single agent34
    5-HT325
    Metoclopramide5
    Dexamethasone4
    Droperidol<1
Two-drug combinations (%)35
    5-HT3 + dexamethasone21
    5-HT3 + other11
    Non 5-HT3 with a non 5-HT33
Combinations of 3 or more drugs23
    5-HT3 + dexamethasone + droperidol9
    5-HT3 + dexamethasone + other14
Table 5.
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Percentage of Study Participants With PONV/PDNV and Related Symptoms30

SymptomPostdischarge (24–72 hours)Overall (0–24 hours)Overall (0–72 hours)
aDefined as emesis, retching, or both.
bDefined as no emesis and no use of rescue medications.
cDefined as complete response and no more than mild nausea.
dDefined as an average score of 2 or higher across all 5 items as measured by the Osoba module.
Vomitinga222430
Moderate-to-severe nausea504147
Required rescue meds284145
Complete response rateb645449
Complete control ratec544539
Functional interferenced353744
SymptomPostdischarge (24–72 hours)Overall (0–24 hours)Overall (0–72 hours)
aDefined as emesis, retching, or both.
bDefined as no emesis and no use of rescue medications.
cDefined as complete response and no more than mild nausea.
dDefined as an average score of 2 or higher across all 5 items as measured by the Osoba module.
Vomitinga222430
Moderate-to-severe nausea504147
Required rescue meds284145
Complete response rateb645449
Complete control ratec544539
Functional interferenced353744
Table 5.
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Percentage of Study Participants With PONV/PDNV and Related Symptoms30

SymptomPostdischarge (24–72 hours)Overall (0–24 hours)Overall (0–72 hours)
aDefined as emesis, retching, or both.
bDefined as no emesis and no use of rescue medications.
cDefined as complete response and no more than mild nausea.
dDefined as an average score of 2 or higher across all 5 items as measured by the Osoba module.
Vomitinga222430
Moderate-to-severe nausea504147
Required rescue meds284145
Complete response rateb645449
Complete control ratec544539
Functional interferenced353744
SymptomPostdischarge (24–72 hours)Overall (0–24 hours)Overall (0–72 hours)
aDefined as emesis, retching, or both.
bDefined as no emesis and no use of rescue medications.
cDefined as complete response and no more than mild nausea.
dDefined as an average score of 2 or higher across all 5 items as measured by the Osoba module.
Vomitinga222430
Moderate-to-severe nausea504147
Required rescue meds284145
Complete response rateb645449
Complete control ratec544539
Functional interferenced353744
The vomiting reflex.
Figure 1.

The vomiting reflex.

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The timeline and settings of PONV and PDNV.2 Reprinted with permission from reference 2.
Figure 2.

The timeline and settings of PONV and PDNV.2 Reprinted with permission from reference 2.

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The percentages of high-risk patients who experienced postoperative vomiting, nausea, and functional interference as a function of the number of prophylactic antiemetics administered. Patients were assessed at 0–24h, 24–72h, and 0–72h after surgery.27 Reprinted with permission from reference 27.
Figure 3.

The percentages of high-risk patients who experienced postoperative vomiting, nausea, and functional interference as a function of the number of prophylactic antiemetics administered. Patients were assessed at 0–24h, 24–72h, and 0–72h after surgery.27 Reprinted with permission from reference 27.

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Interference with daily functioning measured in the POSTOP study.30 Reprinted with permission from reference 30.
Figure 4.

Interference with daily functioning measured in the POSTOP study.30 Reprinted with permission from reference 30.

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Adherence of clinical practice with American Society of Anesthesiologists (ASA) and American Society of Perianesthesia Nurses (ASPAN) guidelines for PONV prophylaxis. The complete response rates associated with compliant and noncompliant prophylaxis were compared at 0–24h, 24–72h, and 0–72h in a prospective study of high-risk patients. Nonoverlapping confidence intervals indicate statistically significant differences between the groups.27 Reprinted with permission from reference 27.
Figure 5.

Adherence of clinical practice with American Society of Anesthesiologists (ASA) and American Society of Perianesthesia Nurses (ASPAN) guidelines for PONV prophylaxis. The complete response rates associated with compliant and noncompliant prophylaxis were compared at 0–24h, 24–72h, and 0–72h in a prospective study of high-risk patients. Nonoverlapping confidence intervals indicate statistically significant differences between the groups.27 Reprinted with permission from reference 27.

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