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Since multiple CNS receptor cites may cause PONV, a single antiemetic agent is often not 100% effective in controlling PONV symptoms in different patients.3 In order to achieve optimized efficacy, CGM-PONV recommend the use of combination therapy with drugs from different classes in adults at moderate risk for PONV.13 The degree of evidence for the effectiveness of different combination treatments presented in the guidelines varies; treatments consisting of ondansetron in combination with droperidol or dexamethasone have been studied the most.13
Prophylaxis in Patients at High Risk for PONV Based on CGM-PONV
CGM-PONV recommend prophylaxis with combination therapy or a multimodal approach consisting of 2 or more interventions in patients who are at high risk for PONV.13 A multimodal approach to PONV prevention may consist of pharmacologic and nonpharmacologic prophylaxis in combination with interventions that reduce baseline risk.20
Pharmacologic Prophylaxis for PONV Based on Practice Guidelines for Postanesthetic Care
Updated Practice Guidelines for Postanesthetic Care (PGPC), developed by the American Society of Anesthesiologists (ASA), were published in February 2013. They provide basic recommendations for prophylaxis and treatment of PONV and are not meant to be used as standards or absolute requirements.21 Updated PGPC evaluated the following drugs for the prophylaxis of nausea and vomiting: antihistamines, antiemetics, tranquilizers, metoclopramide, scopolamine, and dexamethasone.21 While findings from randomized controlled trials support earlier findings that antiemetic drug combinations are effective for PONV prophylaxis, ASA members and consultants drafting the latest PGPC are equivocal about the use of multiple pharmacologic agents for prevention of nausea and vomiting.21
Conclusion
PONV prophylaxis is widely administered in an effort to prevent potential adverse outcomes and increased medical costs associated with inadequately controlled PONV.22 Objective validated risk score assessments are used to estimate a patient’s baseline risk for PONV and facilitate the decision-making process about the number and choice of antiemetics used for PONV prevention. Current CGM-PONV recommend a wait-and-see approach in patients at low risk for PONV, 1 to 2 prophylaxis interventions in adults at mild risk for PONV, and combination antiemetic therapies or a multimodal treatment approach in patients at high risk for PONV.13
The information provided in this article is only a partial synopsis. For full details on all pharmacologic prophylaxis options for PONV, refer to Consensus Guidelines for the Management of Postoperative Nausea and Vomiting.13 Drug approval status is based on information available until February 16, 2018.
References
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