Postoperative Nausea and

Vomiting

Dr Amit Kocheta
DNB Trainee
Anesthesiology
BMHRC
 Introduction
• The most common and distressing symptoms,
which follow anesthesia and surgery, are pain and
emesis.
• During ether era, reported incidence of PONV was
as high as 75–80%.
• Eighty years ago, Flagg suggested that PONV may
result from causes other than anesthetics : “there
are at least three kinds of vomiting”,
– the first of which has been attributed to anesthetics
such as ether,
– the second to reflex responses,
– the last to opioids.
• The incidence of postoperative emesis in some
large studies has been reported to be in the
range of 20–30 %.
• Intractable PONV is the most frequent
anesthetic related cause for unexpected
hospital admission of surgical out patients.
• PONV causes increase in IOP & ICP, suture
dehiscence, esophageal rupture, hematoma
formation & aspiration pneumonitis.
 Definitions
• Nausea : It is an unpleasant sensation referred
to a desire to vomit, not associated with
expulsive muscular movement.
• Retching : When no stomach contents are
expelled even with expulsive muscular efforts.
• Vomiting : It is the forceful expulsion of even a
small amount of upper gastrointestinal contents
through mouth.
 Overview
• Physiology

• Aetiology

• Associated factors

• Management
 Prevention
 Physiology

• Vomiting reflex

Afferent inputs

Processing centre

Motor efferents
 Vomiting Centre
• Located in the medulla

• Represents multiple nuclei involved in

the integration of the vomiting reflex

• The motor component of the vomiting

reflex is mediated by both autonomic
and somatic systems, whose activity is
coordinated in the vomiting centre
 Afferent pathways
• Gastrointestinal tract (5HT3, D2)
Mechanoreceptors located in the wall of the
gut are activated by abnormal distension,
contraction, physical damage or manipulation
during surgery
Chemo receptors located in the mucosa are
triggered by noxious chemical stimuli
Information relayed via the vagus nerve to the
nucleus tractus solarius in the vomiting centre
 Afferent pathways
• Chemoreceptor Trigger Zone
 Area Postrema
 Located in the floor of the 4th ventricle
 Defective BBB for detecting circulating toxins in the
blood and CSF
 Works through the 5-HT3 receptors as well as
dopamine type 2 receptors
• Others
 Vestibular system: responsible for motion sickness
 Cardiovascular system: afferents from cardiac
ventricles and blood vessels
 Higher centers: limbic system, olfactory and visual
cortex
 Pharyngeal afferents (?gag reflex)
Chemoreceptor Trigger Zone
and Emetic Center
Antagonist
5-HT3 RAs Promethazine Atropine Droperidol NK-1 RA

Agonist
5-HT3 Histamine Muscarinic Dopamine (D2)Substance P

Receptor Site Nitrogen mustard

Cisplatin
Digoxin glycoside
Chemoreceptor
Postrema

Trigger
Area

Zone Opioid, analgesics

(CTZ)
Vestibular portion
of 8th nerve

Mediastinum
Parvicellular
Emetic
Reticular N 2O
Center
Formation

?
GI tract distension
Vag Higher centers (vision, taste)
us
Pharynx
 Efferent pathways
• Vomiting reflex is divided into 2 phases
Pre-ejection or Prodromal phase: relaxation of
the gastric muscles followed by small intestinal
retrograde peristalsis
Ejection phase : comprises of retching and vomiting
with expulsion of gastric contents.
• Mediated by autonomic and somatic systems,
coordinated in the vomiting centre
Schematic representation of the
factors influencing nausea and
vomiting
 Risk Factors
• Patient factors

• Preoperative factors

• Intraoperative factors
 Anesthetic factors
 Surgical factors

• Postoperative factors
 Patient Factors
• Age
– Highest in 6-16 age group
• Gender
– Women 2-4x more likely than men
• Obesity
• Non-smoker
• Gastro paresis
– Diabetes, hypothyroidism, pregnancy, h/o
swallowing blood, full stomach, intra-abdominal
pathology
• History of motion sickness, PONV
• Chemotherapy patients
 Preoperative Factors
• Food
Prolonged pre-op fasting
Not starved

• Anxiety

• Premedication
 Intraoperative factors:
Anesthetic
• Intubation
• Deeper plane of anaesthesia
• Gastric inflation during mask ventilation
• Intraoperative dehydration
• Drugs : Opioids, Ketamine compared with
Propofol and Thiopentone
• Inhalation Agents: N20 compared with
Sevoflurane, Isoflurane, Desflurane
• General anaesthesia compared with spinal
and regional anaesthesia
• Neostigmine: in high doses
 Postoperative factors
• Head movement of patient after
waking

• Postoperative pain

• Early ambulation, dizziness

• Early intake of food

 Surgery factors
• Duration of surgery
• Type of surgery
Gynecological
ENT
Abdominal
Head &neck
Squint correction
Risk Score for Predicting PONV
by Apfel
RISK FACTORS:
1 -Female sex
2 - Hx. of motion
sickness or PONV
3 - Nonsmoking status
4 - Use of Postoperative
Opioids

NONE 1 Factor 2 Factors 3 Factors 4 Factors

10 % 21 % 39 % 61 % 79 %
 Management:
Pharmacological Prophylaxis
• Multiple receptors involved in the
vomiting reflex
 5HT-3
 D2
 M1 ACh
 H1
 Neurokinin-1
 Drugs
• Antagonists • Agonists
• 5HT-3 :-Dolasetron, • Steroids
Granisetron,
Tropisetron, • Dexamethasone
Ondansetron • Benzodiazepines
• D2:- Droperidol, • Midazolam
Metoclopramide,
Prochlorperazine • Cannabinoids
• Ach :-Cyclizine,
Scopolamine
• H1 :-Promethazine,
Cyclizine
• Neurokinin-1
:-Aprepitant
The main sites of action of
drugs affecting nausea and
vomiting
 Standard Dosages of Antiemetics
for the Prophylaxis of PONV in
Agent Adults Dosage
Droperidol 0.625 – 1.25 mg Iv 5 min before termination of
anesthesia

Ondansetron 4 mg IV immediately before induction

8 mg PO 1 h before induction
Recent data: more effective- end of anesthesia

Dolasetron 12.5 mg IV intraoperatively

100 mg PO 1 h before induction

Metoclopramide 10 (20) mg IV near the end (not effective when

used alone)

Promethazine 25 mg PO 1 h before induction

12.5 – 25 mg IV immediately before ind.

Prochlorperazine 5 – 15 mg PO 1 h before induction

5 – 10 mg IM 1 – 2 h before ind.; repeat once in
30 min,
5 – 10 mg IV 15 – 30 min before ind; x1

Granisetron 20 – 40 mcg/kg IV
 Standard Dosages of Antiemetics for
the Treatment of PONV in Adults

Agent Dosage
Ondansetron 1 – 4 mg IV postoperatively

Metoclopramide 10 mg IV q 4–6 h prn post-operatively

Promethazine 10 – 25 mg PO prn post-operatively

12.5 – 25 mg IM or IV q4h prn post-operatively

Prochlorperazine 5 – 15 mg PO post-op.
5 – 10 mg IM; repeat once in 30 min prn
5 – 10 mg IV; may repeat once prn

Chlorpromazine 10 – 25 mg PO q4-6h prn

12.5 – 25 mg IM if no hypotension; repeat in 1h

Droperidol 0.625 – 1.25 mg IV prn

Dolasetron 12.5 mg IV post-operatively

 Standard Dosages of Antiemetics for
the Management of POV in Pediatric
Patients
Agent Dosage
Prophylaxis
Dolasetron Age >2y: 1.8 mg/kg IV immediately before ind.

Ondansetron 0.05 mg/kg IV (range: 0.05 – 0.15 mg/kg)

Droperidol 0.015 – 0.075 mg/kg per dose IV

Treatment
Chlorpromazine 0.55 mg/kg PO or IM

Droperidol 0.1 mg/kg per dose IV

Ondansetron 0.05 mg/kg per dose IV

 Ondansetron (Emeset)
• Serotonin 5HT3 antagonist
• Adult dose : 4-8 mg IV
• Pediatric dose : 50 – 100 mcg/kg
IV up to 4 mg
• Greater efficacy in prevention of
vomiting than nausea
• Most effective when
administered at end of surgery
• Headache, dizziness, flushing,
elevated liver enzymes,
constipation
 Droperidol
• Butyrophenone
• Blocks dopamine-2 receptors in the
CTZ and area postrema
• Usual adult dose: 0.625-1.25 mg IV
• Pediatric dose : 50 -75 mcg/kg up to
1.25mg
• Duration of action: up to 12-24 hours
• Adverse effects: sedation, dizziness,
anxiety, hypotension, extra pyramidal
side effects
• More effective for nausea than
vomiting
• FDA BLACK BOX WARNING 2001
– Increased risk of lengthening of the QT
intervals in some patients
– Risk for cardiac patients!!!
 Metoclopramide (Reglan)
• Benzamide
• Blocks dopamine-2 receptors in
the CTZ and vomiting center
• Prokinetic properties that
quicken esophageal clearance,
enhance gastric emptying, and
shorten bowel-transit time
• Less effective than Ondansetron
or Droperidol
• Most commonly administered
dose of 10 mg IV is not effective
for prevention of PONV
 Metoclopramide (Reglan)
• Usual adult dose for PONV: 25-
50 mg IV
– 10-20 mg IV for rescue N/V

• Duration of action: up to 6
hours

• Adverse effects: sedation,

hypotension, extra pyramidal
symptoms, restlessness
 Promethazine (Phenergan)
• Phenothiazine
• Blocks dopamine-2 receptors in the
CTZ and other areas of the brain
• Also blocks histamine-1 receptors
and msucarinic-1 receptors
• Usual adult dose: 6.25-12.5 mg IV
• Duration of action: 4-6 hours
• Adverse effects: sedation,
hypotension, extra pyramidal
symptoms
 Diphenhydramine
(Benadryl)
• Antihistamine

• Suppresses motor-enhanced
vestibular neuronal firing

• Adverse reactions: sedation,

dry mouth, blurred vision,
urinary retention
 Scopolamine
• Anticholinegic
• Transdermal patch
• Blocks the muscarinic-1 receptors in
the cerebral cortex and pons and
histamine-1 receptors in the
hypothalamus and vomiting center
to exert its antiemetic effects
• Suppresses the noradrenergic
system (improved adaptation to
vestibular stimulation)
• 4 hour onset of action
– Needs to be placed the night before for
patients with increased risk of PONV
 Dexamethasone
• Corticosteroid
• Antiemetic action not fully
understood
• Thought to work by antagonizing
prostaglandins or releasing
endorphins that elevate mood,
improving one’s sense of well-
being and stimulating appetite
• Most effective when administered
before induction of anesthesia
 NK1 Antagonists
• Future development in anti-emesis is looking at the
neurokinin 1 (NK-1) receptor, where substance P
is the natural ligand. This receptor is found in the
nucleus tractus solitarius and the area postrema,
as well as the peripheral nervous system. Early
studies of NK-1 antagonists have been promising,
especially in combination with Ondansetron

• Neurokinin (substance P, NK1) antagonists -

impressive antiemetic in the animal model. However,
early clinical data have been disappointing, except for
Aprepitant (Emend®) - has demonstrated
superiority over Ondansetron in chemotherapy
induced nausea and vomiting.
 Complementary Therapies:
Acupuncture and Related
•
Techniques
Traditional Chinese medicine
treated nausea and vomiting with
acupuncture

• Uses needles that are inserted into

traditional acupuncture points in
the body, initiating a series of
physiological events that counter
PONV

• Certain nerve fibers are stimulated

that result in nerve impulses being
sent to the spinal cord
– Endorphogenic cells are stimulated to
release endorphins
 Complementary Therapies:
Acupuncture and Related
•
Techniques
Nerve impulses produced by
acupuncture also transmit to the
periaqueductal gray area of the
midbrain where enkephalin is
released
– Causes a release of the monoamine
neurotransmitters serotonin and
norepinephrine in the spinal cord
• 3rd effect is release of beta-
endorphins and
adrenocorticotropic hormone
(ACTH) from the pituitary gland
into the bloodstream and
cerebrospinal fluid
• Calming of the GI tract
 Complementary Therapies:
Acupuncture and Related
Techniques
• Acupressure
– Uses physical and
mechanical pressure
instead of needles
over the same
meridians of the
body
– P6 point stimulation
 Complementary Therapies:
Aromatherapy
• Dates back as far as
2800 BC
• Herbal preparations and
plant extracts
• Use of oil of ginger as a
prophylactic therapy
• Isopropyl alcohol
• Oil of peppermint
 Complementary Therapies:
Peppermint
• Remedy for
morning
sickness,
dyspepsia, and
other GI
complaints
 Inhalation of Isopropyl Alcohol
Vapors
• Study of 100 healthy
women undergoing
outpatient gynecologic
laparoscopic procedures

• Randomly received 4 mg
Ondansetron or 70%
isopropyl alcohol for
postoperative nausea

• Use of alcohol pads

resulting in quicker relief
of nausea
 Complementary Therapies:
Oral Ginger
• Oral ginger has been
used in China for
treating GI symptoms
such as nausea and
vomiting

• Ginger root, ginger

powder, ginger candy,
and ginger gum

• Ginger oil in form of

aromatherapy

• Role not clearly

defined by research
Strategies to Reduce
Baseline Risk
Thanks