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Anaesthesia and Pain Management

Post-operative Nausea Vomiting PONV

  • This guideline was written by the staff of the Children's Pain Management Service (CPMS) for the Royal Children's Hospital, Melbourne.

    This guideline may NOT be suitable for use in other institutions. 

    Background

    The cause of postoperative nausea and vomiting (PONV) is the complex mechanical and chemical interactions between the brain (vomiting centre, chemoreceptor trigger centre and middle ear) and gastro intestinal tract.

    (Kovac 2007)

    Nausea and vomiting are unpleasant experiences which are rated by patients to be as distressing as pain. PONV is a common recognised complication of general anaesthetic/surgery and the perioperative use of opioids.

    PONV is multifactorial in children due to the patient's history of previous motion sickness or PONV, the surgery type, the anaesthetic type, and agents used, length of surgery, length of fasting time, analgesic and antiemetic medications and techniques employed, the presence of pain, as well as psychological distress.

    PONV can delay recovery and discharge from hospital adding both a resource, cost patient and family burden.

    Combinations of antiemetic medications or interventions appear to be more effective than a single agent. A combination of 5HT3 receptor antagonist ("tron") and dexamethasone given as prophylaxis has shown that less rescue antiemetics were required. (Shug et al 2015 2020)

    There is a recommendation for perioperative prophylaxis antiemetics based on patient age, surgery type, anaesthetic agents and previous history.

    Risk factors which could increase the PONV incidence

    Risk Factors 

    Age > 3, Past history of PONV, History of motion sickness, Post-pubertal girls, Preoperative anxiety

    Surgery type

    Strabismus, Otoplasty, Adenotonsillectomy, Surgery requiring postoperative inpatient (vs day stay),Volatile anaesthesia

    Guidelines for intraoperative prophylaxis for PONV

    For children >2 years who are to receive surgery requiring postoperative analgesia infusions with potential risk of PONV, CPMS recommend a minimum of two antiemetic interventions intraoperatively

    Eg: dexamethasone at induction and propofol supplemental infusion or total intravenous anaesthesia (TIVA) or 2nd antiemetic agent at surgery completion.

    Guidelines for treating Post-Operative Nausea and Vomiting (PONV) Rescue Therapy

    Antiemetic options depend on what  has been given intra and postoperatively

    Below recommendations are local to RCH and incorporate cost considerations

    • Granisetron*

               IV 0.04mg/kg Daily usual maximum1mg dose.

              (prescription limited to Anaesthetic OR Children's Pain Management Service (CPMS) Consultants, Fellows and Registrars)

              OR if no IV access - Ondansetron SL disintegrating tablet 0.1mg/kg usual maximum dose 4mg

    • Metoclopramide

               IV or PO 0.15-0.2mg/kg 6 hourly usual maximum dose10mg/dose

              Consider for bilious vomiting; only continue if effective

    Note the RCH PONV guideline dosing for Metoclopramide differs from the TGA and AMHC recommendations and RCH patients should be dosed as per this guideline.

    • Droperidol

      IV 0.01 mg/kg 8 hourly usual, maximum 0.5mg/dose

      Consider as 3rd line for children 10 years or older; 4th line for children younger than 10 years of age

    • Promethazine

      IV 0.5 mg/kg 8 hourly usual, maximum 25mg/dose

      Consider as 3rd line for children less than 10 years of age; 4th line for children 10 years of age or older


      Note : at RCH cyclizine is the most expensive antiemetic and requires Drug Usage Committee approval to prescribe




      * 

      The 'tron' of choice at RCH is granisetron (due to cost considerations; other centres have co-purchasing agreements for ondansetron IV. If tolerating PO intake, ondansetron oral tablet or solution are also available).



     



    • First version written 1999, Updated April 2023