Prophylaxis of PONV in Adults

Successful management of PONV begins with pre-operative visit.

(1) ASSESS THE RISK OF PONV1

Previous PONV or motion sickness?

Non smoker?

Female?

Receiving post-operative opioids?

Total Score

Please tick appropriate box

and add to give score = 0 - 4

Risks may be further modified by type of surgery and the consequences of PONV.

(2) REDUCE THE RISK IF POSSIBLE

Consider reducing or omitting opioids by using NSAIDs and/or regional anaesthesia.
Omitting nitrous oxide, volatile agents and large doses of neostigmine (>2.5mg) may
beneficial. A propofol infusion and IV fluids may be helpful.

(3) DECIDE IF THE PATIENT REQUIRES PROPHYLAXIS

There is no place for single agent prophylaxis. Use combined therapy if prophylaxis is
appropriate2.
SCORE 0 OR 1

SCORE 2 OR 3

No prophylaxis

2 Drug Prophylaxis from

Treat in Recovery
if necessary

Dexamethasone 4 - 8mg
Droperidol 0.625 - 1.25mg
Ondansetron 4mg

SCORE 4 OR OTHER REASON

TO AVOID PONV
Triple Prophylaxis
Dexamethasone 4 - 8mg

+
Droperidol 0.625 - 1.25mg

+
Ondansetron 4mg

Cyclizine is available as a 4th line agent.

Dexamethasone is best given at induction. Droperidol, Ondansetron and Cyclizine are most
effective when given 20 - 30 minutes from end of anaesthesia3.

(4) DECIDE ON THE PLAN FOR RECOVERY AND THE WARD. PRESCRIBE ON
ANAESTHETIC SHEET AND DRUG KARDEX
References:
1. Apfel C. Anesthesiology 1999; 91: 693-700
2. Tramer M. BMJ 2003; 327: 762-763
3. Gan T.J. Ambulatory Anaesthesiology 2007; 105: 1615-28

Treatment of PONV in Adults

(1) Regular assessment of post-op nausea & vomiting (PONV) score
0 - NO NAUSEA OR VOMITING
1 - NAUSEA ONLY
2 - VOMITING ONCE
3 - VOMITING MORE THAN ONCE

(2) Check for other causes

Hypoxia

Blocked NG Tube

Ensure patient comfort

& positioning

Intra-Abdominal pathology
Ileus

Hypotension
Pain
Hypovolaemia

(3) Treatment (check for ant-emetics given in theatre and recovery)

PONV Score 1 or greater
Yes

No

Ondansetron 4mg IV or IM*

Review in 30 mins to 1 hour

PONV Score 1 or greater

No

Reassess PONV
regularly as per
guideline

Yes

Cyclizine 50mg IV (diluted) or IM*

Review in 30 mins to 1 hour

No

PONV Score 1 or greater

Yes

Check for other causes (see box above)

Call for advice (FY or ST doctor)
Consider Buccastem 3mg
Consider regular Ondansetron 4mg IV 8-hourly
If nausea or vomiting persists, seek advice of acute pain
nurse (bleep 4311) - Ninewells only
* When possible, intravenous (IV) injection is preferable
See formulary / BNF for side-effects and contraindications

RISK SCORE FOR PREDICTING

POST-OPERATIVE VOMITING
Apfel CC. A simplified risk score for predicting
postoperative nausea and vomiting: conclusions
from cross-validations between two centres.
Anesthesiology 1999; 91(3): 693-704
RISK FACTOR

History of PONV / motion sickness ................ 1 point

Non-smoker status ......................................... 1 point

Female gender ............................................... 1 point

Postoperative opioid need .............................. 1 point

Previous PONV or motion sickness?

Non smoker?

Female?

Receiving post-operative opioids?

Total Score

Please tick appropriate box

and add to give score = 0 - 4

Using the above score, if the total is 0, 1, 2, 3 or 4 points,

then the risk of PONV is 10, 20, 40, 60 or 80% respectively.
Use Apfel score in conjunction with the prophylaxis guideline