Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: Executive Summary

Abstract

Postoperative nausea and vomiting (PONV) is a common adverse event after surgery and anesthesia. Optimal management of PONV requires a multidisciplinary approach, with evidence-based care and appropriate institutional infrastructure.1 The Fifth Consensus Guidelines brought together an international, multidisciplinary panel of experts to review the available scientific literature to provide a comprehensive, evidence-based update on PONV management. This is the executive summary of the 5th PONV consensus guideline. The full guideline document is available as supplementary digital content (Supplemental Digital Content 1, appendix 1, https://links.lww.com/AA/F568). This iteration of the guideline provides updates on topics including PONV risk factors, risk reduction interventions, single antiemetic and combination options for PONV and postdischarge nausea and vomiting (PDNV), PONV management in children; pharmacoeconomics, PONV management within enhanced recovery pathways (ERP). The rationale for the updated PONV management algorithm will also be discussed. The current guidelines are prepared following the Cochrane Handbook for conducting the search, the PRISMA 2020 for reporting, and PRISMA-S extension for searches (SDC Supplemental Digital Content 1, appendix 1, https://links.lww.com/AA/F568 and Supplemental Digital Content 2, appendix 2, https://links.lww.com/AA/F569). The quality of evidence is graded using the system developed by the American Society of Anesthesiologists’ (ASA) acute pain management practice guideline,1 and was used in the previous PONV consensus guideline (SDC 3, appendix 3, https://links.lww.com/AA/F570). The gradings are highlighted in bold. GUIDELINE 1. IDENTIFY PATIENTS’ RISK FOR PONV PONV risk assessment tools and risk stratification protocols are effective in reducing PONV (B1).1 PONV risk scores can be used to inform and guide therapy, reducing institutional level PONV rates, using the Apfel simplified score (Figure 1A) for risk stratification.1,2 Patients without any Apfel risk factors should be considered low risk; those with 1 to 2 risk factors as medium risk; patients with ≥3 as high risk of PONV. Reminder systems increase adherence to a risk stratified management algorithm.3Figure 1.: A, Simplified risk score from Apfel et al to predict the patient’s risk for PONV. 0, 1, 2, 3, and 4 risk factors correspond to PONV risks of approximately 10%, 20%, 40%, 60%, and 80%, respectively. B, Simplified risk score for PDNV in adults from Apfel et al to predict the risk for PDNV in adults. 0, 1, 2, 3, 4, and 5 risk factors correspond to PDNV risks of approximately 10%, 20%, 30%, 50%, 60%, and 80%, respectively. PDNV = post-discharge nausea and vomiting; PONV = postoperative nausea and vomiting; PACU = post-anesthesia care unit. Reproduced with permission from ASERP. For permission requests, contact [email protected].There is ongoing discussion on adopting a more liberal approach to PONV prophylaxis1 to address undetected risk factors, non-adherence to risk-stratified PONV algorithms and ambiguity in interpreting individual risk factors.4 This is supported by increased adoption of general multimodal PONV prophylaxis as part of enhanced recovery pathways.5 Increasing evidence supports the safety of antiemetics at perioperative dosages, this may shift the paradigm further towards liberal combination antiemetics.6 However, practice shifts towards general, multimodal prophylaxis does not discredit the validity of PONV prediction scores, nor an appropriately implemented risk-adapted PONV protocol. Novel PONV Risk Factors Literature since the last PONV consensus guideline reported several novel risk factors for PONV. A retrospective study of 160,000 patients identified a strong association between lower preoperative physical fitness (ASA classification 3) and decreased likelihood of developing PONV (SDC 3, Table S1, https://links.lww.com/AA/F570 B1).7 A smaller retrospective analysis demonstrated that higher hemoglobin and hematocrit (Hct) were associated with less PONV (B1),8 with Hct level >39.3% being optimal. Both elevated neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were associated with increased PONV risk (B1).9 Avoiding intraoperative hypotension (B1)10 and goal directed hemodynamic management (A1)11 may reduce the risk of PONV. Kim et al found that propensity matching, overweight and obese patients [body mass index (BMI) > 25 kg/m2 and > 30 kg/m2 respectively] had significantly lower incidence of PONV than patients with lower BMI (B1).12 Type of Surgery Patients undergoing bariatric surgery have higher rates of PONV (B1).13 Other higher risk surgeries include laparoscopic cholecystectomy, urological procedures, and knee arthroplasty (B1).14 Breast, gynecologic and obstetric surgeries are also associated with increased risk.15 At the population level, adding more risk factors to the prediction model is unlikely to improve model performance. Additional factors should be considered on a case-by-case basis if vomiting poses a significant medical risk, such as an increased intracranial pressure or in conjunction with wired jaws in the postoperative phase. PDNV Risk Evaluation PDNV presents a significant risk as patients no longer have access to fast-onset intravenous (IV) antiemetics or direct care. A simplified PDNV score included 5 risk factors: female gender, age <50 years, history of PONV, opioid use in the post-anesthesia care unit (PACU), and nausea in the PACU (Figure 1B),1 the incidence of PDNV with 0 to 5 risk factors to be about 10%, 20%, 30%, 50%, 60%, and 80%, respectively. Other risk factors may include previous PDNV, length of surgery, antiemetic use in the PACU and postdischarge pain.1 Genomics, Genetics, and Polymorphism Emerging evidence suggests that PONV risk and antiemetics efficacy may be influenced by genetic polymorphisms and variation in gene expression (epigenetics). This includes genetic determinants of cytochrome P450 (CYP 2D6), serotonin, dopamine and acetylcholine receptor activities (SDC 3, Table S2, https://links.lww.com/AA/F570).16 It is however unclear how this may influence PONV risk stratification in the future.17 The Impact of Sex/Race/Gender/Social Determinants on PONV Social determinants, such as sex, gender, race, and socioeconomic status may lead to disparities in health care access, treatment, and outcomes but are infrequently considered in randomized controlled trials (RCTs) related to PONV management.18 Patients with lower socioeconomic status are less likely to receive antiemetics after correcting for potential confounders. The interaction between race/ethnicity and PONV risk is a topic of ongoing debate. It has been observed that African American patients are more frequently undertreated when compared to white patients.19 High-risk Hispanic patients were more likely to experience PONV than white patients.19 Racial disparity in PONV management can be avoided through standardization of care. Sex and gender may impact the perioperative management of PONV, and transgender patients represent a potentially vulnerable population. Transgender patients undergoing facial gender affirming surgery (GAS) were found to have significantly higher risk of PONV than cisgender patients undergoing oral and maxillofacial surgery.20 Gravid women who underwent non-obstetric procedures with general anesthesia have comparable PONV incidence compared to non-gravid patients.21 Fewer prophylactic antiemetics were given among gravid patients, which may be related to the lack of specific recommendations for PONV prophylaxis during pregnancy. GUIDELINE 2. REDUCE BASELINE RISK FOR PONV Approaches for decreasing baseline risk are summarized in SDC 3, Table S3, https://links.lww.com/AA/F570. Propofol Total Intravenous Anesthesia Propofol total intravenous anesthesia (TIVA) alone has comparable PONV risk to volatile anesthesia plus 5-hydroxytryptamine 3 (5-HT3) receptor antagonists or droperidol (A1). Both propofol TIVA and subhypnotic dose propofol infusion are effective in combination with other antiemetics (A2).1 Multimodal Systemic Analgesia Effective analgesic interventions for minimizing PONV risk include acetaminophen (A1), intraoperative ketamine (A1), and esmolol infusion (A2). Lidocaine infusion can reduce PONV risk in laparoscopic abdominal procedures, but not in other surgery types (A1).1 Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 inhibitors (A1) are also effective for reducing PONV risk. However, nonselective NSAIDs may be associated with anastomotic leak in gastrointestinal (GI) surgery and their use should be carefully considered.1 A large systematic review and meta-analysis (SRMA) found that low dose gabapentinoids (<300 mg pregabalin/day or <900 mg gabapentin/day) reduced the risk of PONV despite demonstrating no significant analgesic efficacy (A1).22 While opioid-free anesthesia reduces PONV when compared to opioid-based anesthesia (A1),23 it is unclear if this is comparable with multimodal opioid-sparing analgesia. Neuraxial and Regional Anesthesia Epidural analgesia reduces the risk of PONV (A1), opioid-containing epidural mixture is associated with higher risk of PONV than plain local anesthetic preparations (B1).24 Other effective regional anesthesia techniques include transversus abdominis plane (TAP) block before abdominal surgery (A1), quadratus lumborum block (A1) and continuous wound Other Risk as anesthesia the risk of PONV (A1). during not PONV risk reduces the incidence and of PONV in Supplemental reduced the risk of and PONV (A1).1 may be more effective in surgeries reduced the risk of PONV and antiemetic in patients undergoing was no more effective than in reducing PONV risk A of that not reduce PONV risk GUIDELINE PONV 2 RISK FOR PONV in this is summarized in Table 1. of antiemetics are summarized in the SDC 3, Table https://links.lww.com/AA/F570. Table 1. and for of PONV in SDC for mg mg At 5 mg mg At mg of surgery mg of surgery mg mg 4 mg mg of surgery mg mg of surgery mg At or 2 before surgery 2 mg for of the and be considered on recommendations are evidence-based and not the drugs have an for postoperative nausea and are receptor antagonists have than is a common was of the receptor antagonists by the and dose was by intravenous (IV) or oral 1 before is more effective than for PONV less than and A retrospective study of patients reported that no patients or developed as a direct of this included patients baseline was has a longer of than other receptor It is more effective than single dose in reducing and comparable to being at While the dose of is it has been that dose of may be more in obese patients, without an increase in Other was by the for PONV. an of to 3 mg at the of surgery has been for At of 2 to 3 was more effective than for Both and are not available in the but are available in of and may have longer of than other A dose of mg was to 4 mg being comparable or to It is less effective than and was more effective at than but less effective than for The PONV dose of is 4 to It was of the effective single drugs for in the large meta-analysis and mg dose to have the antiemetic and analgesic A Cochrane of as as a large reported that a single dose of to not increase the risk of postoperative or including in patients with (A1).1 can postoperative in patients with but the of is or and the was not associated wound an is effective for PONV prophylaxis at dose of 5 mg (A2). mg is the dose as a antiemetic and effective in patients who had PONV prophylaxis to mg given alone or in combination with other antiemetics not lead to significant nor For PONV the dose of droperidol is mg and is the of surgery (A1).1 patients who developed PONV despite droperidol 1 to mg had efficacy as 4 to was a a in the use of droperidol to the risk of At used for PONV, the potential observed with droperidol is to that of of drugs not increase the risk of A retrospective study of patients reported that droperidol not increase the incidence of nor to 2 mg has comparable efficacy and to receptor antagonists (A1) and is more effective than at anesthesia or of surgery not For PONV treatment, 1 mg had to 4 mg but with more is effective as a for prophylaxis if after of intraoperative antiemetic efficacy than It is less effective than other and has efficacy when to other is not for PONV prophylaxis other dopamine antagonists are not is an that was used for prophylaxis nausea and vomiting is an effective to a multimodal PONV is a receptor with a of approximately A mg oral is available in the an mg is common in other It is also available as a for infusion and is available in a mg dose and as a with of receptor within 5 of It is the with the for PONV to be more effective for vomiting years, has been an increased on mg likely to in but is of direct to of mg to or to a multimodal significantly reduced the risk of PONV. is more effective compared to receptor and is comparable with combination for of is a receptor antagonists with a of is evidence is to have efficacy to other receptor is from recommendations to a lack of is effective for PONV prophylaxis The of and when used for PONV prophylaxis are associated with the use of include and It is also effective in combination with dose is effective for the and of PONV. associated with include and potential for with at high can be on the of surgery or the before surgery, and reduces the risk of PONV for after surgery (A1). include and evidence suggests that may increase the risk of postoperative following Other the risk of PONV and also reduces postoperative include hypotension and which may PACU was associated with reduced risk of following given towards the of surgery, was effective for PONV in the postoperative It may be less effective than antiemetics such as in reduces the risk of PONV, but the and is not the risk of the panel does not the use of for the of PONV A Cochrane systematic review of as PONV found low quality of was no more effective than reduced the for (A1). A study reported that the of surgery was effective in reducing PONV found that may reduce the risk of but not reduce the risk of at the of the is comparable to PONV of the the is effective in reducing the incidence of PONV, when is evidence that may be effective as a but it does not to be effective for PONV The panel to the use of general multimodal PONV in adults. is evidence that appropriate use of combination is likely to be more effective than is antiemetics be at lower when used as a part of multimodal Table 2. of for PONV in Supplemental Digital Content 3, appendix 4, https://links.lww.com/AA/F570 for 3 antagonists reported reported reported reported evidence 3 antagonists reported reported reported Other the antiemetic 3 reported reported reported reported Other 3 combination reported reported reported reported Other combination or antiemetic reported reported Propofol reported reported reported 4 reported reported Propofol antiemetics 5-hydroxytryptamine 3, large 4 postoperative nausea and A meta-analysis by et al an of and combination options for the of on the of options which demonstrated efficacy included receptor plus receptor receptor plus and receptor plus antiemetic are to be more effective than for PONV This provides an evidence-based approach to combination antiemetic using from a evidence on combination with 3 or more mg is effective in to and propofol mg is effective in to and in to and is also is on the efficacy of adding a or antiemetic in the last consensus has been an increase in the of antiemetic reported within the A of other antiemetics is summarized in SDC 3, Table https://links.lww.com/AA/F570. Evaluation of antiemetics used in conjunction with risk reduction interventions is summarized in SDC 3, Table https://links.lww.com/AA/F570. and demonstrated efficacy when used in to receptor antagonists and (A1).1 This may be in patients or procedures who 3 or more prophylactic to PONV in to an approach to risk PONV prophylaxis and (Figure Risk should be considered and implemented if patients undergoing surgery and anesthesia will have at risk for PONV, a general multimodal approach is for PONV patients with 3 or more PONV risk factors, is a of on the use of 3 or more prophylactic the use of risk and are to the of risk as and the impact of PONV in Patients who PONV despite prophylaxis should receive from a to the prophylactic for PONV management in adults. of recommendations for PONV management in including risk stratified and of postoperative nausea and 5-hydroxytryptamine PONV, postoperative nausea and vomiting; total intravenous anesthesia. for use in Reproduced with permission from ASERP. For permission requests, contact [email PONV a of evidence on PONV treatment, this presents a in developing evidence-based guidelines or recommendations on the and safety It may be to that drugs which are effective for PONV prophylaxis also be effective for treatment, but such approach is not without Patients should receive from a to the prophylactic more than has of a dose of a receptor or may be considered if no are should antiemetics such as and in the is not an effective to A systematic on PONV after prophylaxis or no For of antiemetic patients, 4 to and droperidol 1 to are effective options mg has efficacy (A2). Propofol to mg is effective as for PONV For patients other receptor antagonists not provide further with or low low and were and nausea and vomiting presents a significant risk to postoperative patients who no longer have access to antiemetics or direct care after being from the or medical Patients at high risk of PDNV should be given antiemetics before a significantly reduced the incidence of PDNV and use of antiemetics on 1 and antiemetic is oral which reduced the risk of PDNV but was associated with higher risk of be given to patients on for at at on 1 and 2 significantly reduced PDNV GUIDELINE RISK postoperative vomiting and postoperative nausea and vomiting (PONV) are as is more in the of nausea is or for PONV risk in the in the Postoperative score (Figure and the Postoperative in score (Figure A, in the Postoperative for in 0, 1, 2, 3, 4, 5 or risk factors correspond to risks of approximately and respectively. B, Postoperative in score to predict in 0, 1, 2, 3, or 4 risk factors correspond to risks of approximately 10%, 30%, or respectively. = postoperative vomiting; PONV = postoperative nausea and to the risk factors identified by other include female sex, use of and volatile to may an approach to risk from with other risk However, this risk and of risk. Risk Total Intravenous Anesthesia propofol TIVA reduces and PONV rates compared to anesthesia with prophylaxis SDC 3, Table propofol may have a during volatile and be and A reported that compared to a therapy, a reduced and PONV However, in the of and and the for preoperative in is reduce PONV when compared to but not when compared to a of infusion is less effective than a that oral in the PACU reduced opioid and PONV Neuraxial and Regional Anesthesia The efficacy and of and regional anesthesia in minimizing opioid use and PONV is to study techniques may PONV, their should be to the and individual risk A meta-analysis found evidence that perioperative reduced but not plus infusion may be more effective for in the efficacy is comparable to Intravenous acetaminophen reduces PONV in undergoing surgery this population are with reduces PONV rates compared to or (A1).1 Intravenous reduces PONV and risk for the during procedures is also more effective than or for (A1). are from surgery and Factors intraoperative not in in of to at the of the were associated with comparable PONV during also not reduce the risk of of in The and safety of receptor to in are Table in lower incidence of compared to in without in to be in patients with Table of in the Supplemental Digital Content 3, appendix 4, https://links.lww.com/AA/F570 for to 4 mg to mg to mg to 2 mg to mg to 25 mg to 4 mg 3 to mg not effective compared to or alone effective alone not risk is a effective antiemetic in patients dose of not significant to a 4 mg not provide is on the use of in that in in comparable to those with TIVA is effective as PONV prophylaxis in of propofol infusion may also as a risk prophylaxis in is more effective than single in plus is the combination (A1), on plus or plus droperidol are more plus droperidol is less effective than plus risk a single retrospective study suggests a when adding a or to and This from a retrospective analysis using A found evidence for that and reduces (A1), when was before A Cochrane review reported a of such as evidence is of low to PONV in For evidence-based of in a approach as in This with baseline risk and which in the approach to baseline risk (SDC 3, Table and of prophylactic for management in of recommendations for management in including risk risk-stratified and of postoperative 5-hydroxytryptamine PONV, postoperative nausea and vomiting; total intravenous anesthesia. Reproduced with permission from ASERP. For permission requests, contact [email patients to from prophylaxis that with guideline patients not from prophylactic risk prediction a in the risk between patients with and risk factors, is evidence prophylactic with than adherence to in PONV prophylaxis is the and the safety of antiemetics such as and the use of a single prophylactic or in patients without risk For patients with or risk factors, to a and is For patients with or more risk factors, the current evidence does not the of a should be on baseline risk factors through interventions as of use of total intravenous of local and regional anesthesia and of multimodal GUIDELINE PONV of PONV include quality experience of outcomes of and it is also to from the include direct of and and PONV management evidence-based and of care. Racial disparities in perioperative care can to increase in direct and can be increased by to the which the likelihood that of PONV practice may be by of and recovery pathways can improve PONV guideline reducing PONV incidence and of This also the of PONV prophylaxis as an part of the perioperative evidence suggests that the efficacy of interventions is in may be and potentially tools for GUIDELINE recovery pathways should include general, multimodal PONV and risk interventions such as the use of opioid-sparing and regional enhanced recovery protocols adherence for PONV management (SDC 3, Table https://links.lww.com/AA/F570). for PONV Table 4 as basis for the Table for PONV of risk assessment is in PONV experience observed and of the genetic and to PONV in also may to risk for PONV, and suggests that elevated preoperative may be for individual receptor and PONV risk the in and their potential for The PONV risks associated with techniques to PONV should be to include PONV outcomes in their Novel and digital health potentially and PONV. and are likely to be to risk and digital health such as be to provide direct and the or of drugs A combination of with is in the for should on the of antiemetic and and reduction The receptor is of of high efficacy and as as potential and of interventions such as and may While has demonstrated low efficacy for PONV, has but that be effective in combination with PONV management in specific the PONV risk and that for specific including patients, and patients more of the impact of PONV on quality of and and systems may be to patients the full of perioperative PONV their to to on the of PONV to patients and in to health The of and should be part of and are have in and access to risk and those pathways will be with The has a document on for for A guide for PONV management include and outcomes of with from as as a document the of PONV related the evidence in a nausea and and 1, 1 postoperative nausea and vomiting the of general, multimodal PONV it is to evidence antiemetic combination for as as appropriate While is evidence that individual antiemetics in their it is not how this to the efficacy of combination are PONV risk scores that are for risk stratification at a population level, should be of factors which PONV risks and management. is a of literature on the management of PONV in in PONV management in should an approach, using evidence-based the of on the efficacy of or more antiemetics for prophylaxis in high patients, risk reduction interventions and adopting interventions as part of the multimodal PONV prophylaxis are The paradigm shift towards for further in the to PONV risk assessment and and institutional on PONV management should include to the socioeconomic and of Society This of guidelines have been by the following American Society for American of American of American of American of American Society of American Society of Anesthesia and of Society of Anesthesiologists’ Society of of Society of Society of of Society of Society of and Society of Society of Society of of of Society of Society for Anesthesia Society for Anesthesia African Society of of The following have or or from the following in supplementary digital and and for scientific from The PONV consensus was supported in part by from the American Society for which have from and This was

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