Postoperative Nausea and Vomiting (PONV) Management

Algorithm Steps

1. ▶

   Start

   Preoperative PONV Risk Assessment

   Identify risk factors before surgery

   1. ●

      Action

      Apfel Simplified Risk Score

      Count number of risk factors present

      • 1. Female sex
      • 2. Non-smoker
      • 3. History of PONV or motion sickness
      • 4. Postoperative opioids expected
      • Risk of PONV:
      • 0 factors: 10%
      • 1 factor: 21%
      • 2 factors: 39%
      • 3 factors: 61%
      • 4 factors: 79%
      1. ◆

         Decision

         Risk Level?

         Based on Apfel score and surgery type

         1. ●

            Action

            Low Risk (0-1 factors)

            No routine prophylaxis needed

            • Consider single agent for high-risk surgery
            • Have rescue antiemetics available
            • Optimize hydration
            • Avoid unnecessary opioids
            1. ●

               Action

               Intraoperative Risk Reduction

               Anesthetic technique modifications

               • TIVA: reduces PONV vs volatile by ~25%
               • Avoid nitrous oxide in high-risk patients
               • Regional anesthesia when appropriate
               • Multimodal analgesia (NSAIDs, acetaminophen, regional)
               • Adequate hydration (20-30 mL/kg)
               • Sugammadex > neostigmine for reversal
               1. ◆

                  Decision

                  PONV in PACU?

                  Patient experiencing nausea or vomiting

                  1. ●

                     Action

                     Rescue Treatment

                     Use DIFFERENT class than prophylaxis

                     • If no prophylaxis given:
                     • Ondansetron 4 mg IV
                     • If ondansetron given for prophylaxis:
                     • Promethazine 6.25-12.5 mg IV OR
                     • Droperidol 0.625 mg IV OR
                     • Dexamethasone 4-8 mg (if not given) OR
                     • Propofol 20 mg IV (rescue only)
                     • If multiple prophylaxis agents given:
                     • Use agent from different class
                     • Consider propofol 20 mg IV for rescue
                     1. ●

                        Action

                        Refractory PONV

                        Not responding to rescue

                        • Ensure no surgical cause (ileus, bleeding)
                        • Prochlorperazine 10 mg IV/IM
                        • Promethazine 12.5-25 mg IV
                        • Consider acupuncture (P6 point)
                        • Consider NK1 antagonist if available
                        • Evaluate for electrolyte imbalance
                        1. ✓

                           Outcome

                           PONV Managed

                           Patient comfortable for discharge

                  2. ●

                     Action

                     No PONV - Discharge Criteria Met

                     Standard PACU discharge

                     • Tolerating clear fluids
                     • No active nausea
                     • Prescribe PRN antiemetic for home if high-risk
                     • Patient education on when to seek care
         2. ●

            Action

            Moderate Risk (2 factors)

            1-2 prophylactic interventions

            • CHOOSE 1-2:
            • Dexamethasone 4-8 mg IV at induction
            • Ondansetron 4 mg IV at end of surgery
            • Droperidol 0.625-1.25 mg IV
            • PLUS reduce baseline risk:
            • TIVA (propofol-based) if possible
            • Minimize opioids
            • Adequate hydration
         3. ●

            Action

            High Risk (3-4 factors)

            Multimodal prophylaxis required

            • COMBINATION THERAPY (≥2 agents from different classes):
            • Dexamethasone 4-8 mg IV at induction
            • PLUS Ondansetron 4 mg IV end of surgery
            • PLUS consider: Droperidol 0.625 mg OR
            • Scopolamine patch OR NK1 antagonist
            • REDUCE BASELINE RISK:
            • TIVA with propofol
            • Avoid nitrous oxide
            • Minimize neostigmine (use sugammadex)
            • Multimodal analgesia (minimize opioids)
            • Adequate IV fluids