Prophylaxis and Treatment of Nausea and Vomiting

Prophylaxis of Nausea and Vomiting. Drugs evaluated by these Guidelines for the prophylaxis of nausea and vomiting include: (1) antihistamines, (2) 5-HT3 antiemetics, (3) tranquilizers/neuroleptics, (4) metoclopramide, (5) scopolamine, and (6) dexamethasone.

Antihistamines. One new RCT comparing promethazine with placebo corroborates findings of reduced nausea and vomiting reported in the original Guidelines (Category A3-B evidence).1 

5-HT3 Antiemetics. Meta-analysis of new double-blind RCTs corroborate findings reported in the original Guidelines indicating that 5-HT3 antiemetics compared with placebo are effective in the prophylaxis of postoperative nausea and vomiting, and reduced use of rescue antiemetics (Category A1-B evidence). Findings for specific 5-HT3 antiemetics are: dolasetron (reduced vomiting),2–6  granisetron (reduced vomiting),7–11 ondansetron (reduced vomiting and rescue antiemetics),7–9,12 –24 and tropisetron (reduced vomiting and rescue antiemetics).14,25–29  New RCTs are equivocal regarding the effect of palonosetron on postoperative nausea and vomiting (Category A2-E evidence).30,31  Two new double-blind RCTs indicate that ramosetron is effective in the prophylaxis of postoperative nausea, vomiting, and use of rescue antiemetics when compared with placebo controls (Category A2-B evidence).32,33 

Tranquilizers. Meta-analysis of new double-blind RCTs corroborate findings reported in the original Guidelines that inapsine (droperidol) effectively reduces postoperative nausea, vomiting, and use of rescue antiemetics when compared with placebo‖5  (Category A1-B evidence).19,34–38  New double-blind RCTs also indicate that haloperidol is effective in the reduction of postoperative nausea, vomiting, and rescue antiemetic use (Category A2-B evidence).13,35,37,39  One new RCT indicates that dixrazine is effective in the prophylaxis of postoperative nausea when compared with placebo (Category A3-B evidence), with equivocal findings reported for postoperative vomiting, headache, dizziness, and anxiety (Category A3-E evidence).40  New literature is insufficient to further evaluate postoperative nausea and vomiting findings, as reported in the original Guidelines, for the following drugs: hydroxizine (Category A3-B evidence), perphenazine (Category A3-B evidence), and prochlorperazine (Category A1-E evidence).

Metoclopramide. Meta-analysis of new double-blind RCTs comparing metoclopramide (10 mg) with placebo controls report no statistically significant differences in nausea and vomiting in the immediate postoperative period (Category A1-E evidence), but indicate efficacy in the reduction of vomiting during the first 24-h postoperative period (Category A1-B evidence).14,18,23,41–44  Statistically significant differences were reported in the original Guidelines for nausea and vomiting without indicating time of measurement (Category A1-B evidence).

Scopolamine. New double-blind RCTs comparing transdermal scopolamine with placebo patch corroborates findings of reduced nausea and vomiting reported by the original Guidelines (Category A3-B evidence), with no differences reported in dizziness, drowsiness, fatigue, blurred vision, or dry mouth (Category A3-E evidence).45,46 

Dexamethasone. Meta-analyses of new double-blind RCTs comparing dexamethasone with placebo controls corroborate findings reported in the original Guidelines indicating that this antiemetic is effective in the prophylaxis of postoperative vomiting and reduced use of rescue antiemetics, and for the prophylaxis of nausea when higher doses are administered (Category A1-B evidence).8,12,24,26,29,36,37,39,41,43,44,47–56 

The consultants and ASA members agree that the pharmacologic prophylaxis of nausea and vomiting improves patient comfort and satisfaction, reduces time to discharge, and should be done selectively.

Multiple Pharmacologic Agents for Prophylaxis of Nausea and Vomiting. New RCTs comparing two antiemetic drugs with single antiemetic drug controls corroborate findings reported in the original Guidelines indicating that antiemetic combinations are effective in the prophylaxis of postoperative nausea and vomiting (Category A2-B evidence) with no differences in headache, dizziness, drowsiness, anxiety, or akathisia/restlessness reported3,10,11,26,36,42,57–66  (Category A2-E evidence). These RCTs consisted of comparisons among a variety of drug combinations, and the number of studies evaluating similar drug combinations was insufficient for meta-analysis.

The consultants and ASA members are equivocal regarding whether multiple pharmacologic agents should be used for the prophylaxis of nausea and vomiting.

Treatment of Nausea and Vomiting. The original Guidelines indicated that the use of ondansetron is effective for treating vomiting during recovery (Category A1-B evidence); new literature is insufficient to further evaluate this finding. Although the original Guidelines did not report findings for other specific antiemetic treatments for nausea and vomiting, evidence collected at that time indicated that dolasetron and tropisetron were effective (Category A2-B evidence).

The consultants and ASA members agree that the pharmacologic treatment of nausea and vomiting improves patient comfort and satisfaction, reduces time to discharge, and should be done.

Multiple Pharmacologic Agents for Treatment of Nausea and Vomiting. The literature continues to be insufficient to evaluate the impact of multiple pharmacologic agents compared with single agents for the treatment of nausea and vomiting.

The consultants and ASA members are equivocal regarding whether multiple agents should be used for postoperative treatment of nausea and vomiting.

Recommendations for Prophylaxis and Treatment of Nausea and Vomiting. Antiemetic agents should be used for the prevention and treatment of nausea and vomiting when indicated. Multiple antiemetic agents may be used for the prevention or treatment of nausea and vomiting when indicated.

Read Also: ACUPUNCTURE FOR POSTOPERATIVE NAUSEA AND VOMITING

Source: Practice Guidelines for Postanesthetic Care: An Updated Report by the American Society of Anesthesiologists Task Force on Postanesthetic Care