PONV and Antiemetic Drugs

Postoperative Nausea – PONV

Postoperative Nausea – PONV

By Kai Knudsen, Senior Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.
Updated 2018-12-21

Postoperative nausea and vomiting (PONV) has long been a significant problem in anesthesia and intensive care. In fact, this problem is the most worrying of many patients for their imminent anesthesia. In the preoperative interview, there is often concern about postoperative nausea that the patient first addresses. It has been shown that the choice of anesthesia technique is important for the emergence of PONV as well as the presence of a variety of risk factors as well as the type of surgery that is relevant. PONV can be prevented to some extent by administering one or more antiemetics peroperatively. Inhalation anesthesia produces significantly more PONV compared to intravenous anesthesia, however, no significant difference between desfluran and sevoflurane has been demonstrated. The incidence of PONV is around 10-20%, in some groups up to 40%. The use of nitrous oxide gives an increased risk of nausea. Blood pressure drops, bradycardia and hypoxia can trigger nausea and vomiting as well as prolonged permanent or constipation. Of course, the type of surgery also plays a part. High risk of PONV is present in abdominal surgery and chest surgery. Diabetes causes prolonged may bowel motility. High doses of neostigmine for reversal of muscle relaxants causes increased risk of PONV.

As a preventive treatment, dopamine receptor blockers (droperidol, metoclopramide) or 5-HT3 blockers (ondansetron, granisetron) are usually used. The commonly used drugs are ondansetron (Zofran), granisetron (Kytril), betamethasone (Betapred), dexamethason, metoclopramide (Primperan) or droperidol (Dridol). Granisetron is significantly more long-acting compared to ondansetron. A combination of 5-HT3 blockers plus betamethasone or dridol has a better effect than just one drug. The combination of 5-HT3 blockers with dridol gives approximately the same positive effect as a combination with betamethasone. A probably better alternative to betametason is dexametason where the scientific evidence of prophylactic effect against nausea is greater.

Proposals for prophylaxis against PONV:

  • Small risk for PONV: ondansetron only.
  • Moderate risk of PONV: ondansetron plus betamethasone.
  • High risk of PONV: ondansetron, droperidol plus betamethasone.

Transient ECG changes, including prolongation of QT interval have been reported rarely with 5-HT3 blockers. Caution should be exercised in patients with prolonged QT syndrome or arrhythmias.

Risk factors for PONV are:

  • Young patient
  • Female gender
  • Anxious patient
  • Easy to get sick or sick
  • Non-smoker
  • Earlier nausea in anesthesia
  • Constipation or other stomach upsets
  • Long-term fasting
  • Use of opioids postoperatively
  • Gall bladder disease

Atropine (Atropine®)

Anticholinergic drug.

Dosage: 0.5 mg i v as prophylaxis = 1 ml. 0.5 mg/ml solution, prevents bradycardia and nausea secondary to ventricular retention and vomiting. Repeat to max 1 mg per treatment.

Standard dose: 0.5 mg x 1 i v at PONV and bradycardia episodes.

Cave: Caution in Tachycardia, Cardiac Disease, Hyperthermia, Urinary Retention, Accommodation Difficulty, Confusion.

Betametason (Betapred®)

Water-soluble glucocorticoid, antiemetic drug.

Dosage: 4 mg i v as prophylaxis, 4 mg/ml solution = 1 ml.

Standard dose: 4 mg x 1 i v at PONV.

Cave: Caution in osteoporosis, cot compressions, newborn bowel ducts, psychosis, fashion, ulcer ventriculi, tbc, diabetes (raises blood sugar), hyperglycemia, hypertension, cardiac insufficiency.

Dexametason (Dexametason®)

A synthetic corticosteroid with mainly glucocorticoid and antiemetic effect.

Dosage: 8-16 mg orally as treatment.

Standard dose: 8 mg x 1 p o for PONV.

Caution: Caution in osteoporosis, vertebral compressions, newly diagnosed intestinal anastomoses, psychoses, mania, ventricular ulcers, tuberculosis, diabetes (raises blood sugar), hyperglycemia, hypertension, heart failure.

Droperidol (Dridol®)

Dopamine antagonist, neuroleptic drug, antiemetic.

Dosage: 0.5-2.5 mg (most effective dose 1 mg) 0.2-1 ml, 2.5 mg/ml solution.

Standard dose: 0.4 ml, 1 mg. ECG monitoring 2-3 hours after injection

Side effects: Nightmares, stiffness, rigidity, dystonia.

Contraindications: QT-prolongation, Phaeochromocytoma

Granisetron (Kytril®)

Antiemetic drug, a serotonin antagonist.

Dosage: 3 mg is given as prophylaxis, 1 mg/ml solution = 3 ml. An additional dose can be given per day. Maximum dose 6 mg per day.

Standard dose: 3 mg (3 ml) is given intravenously at PONV.

Contraindications: Subileus. Severe liver failure. Previous reactions to selective serotonin antagonists.

Metoclopramide (Primperan®)

Antiemetic drug, dopamine receptor blocker.

Metoclopramide has a centrally acting antiemetic effect and a motility promoting effect within the gastrointestinal tract.

Dosage: 5-10 mg is given as prophylaxis, 5 mg/ml solution = 1-2 ml. An additional dose can be given per day. Max 10 mg per day. 0.15 mg/kg for children.

Standard dose: 5 mg (1 ml) is given intravenously intravenously at PONV.

Caution: Extrapyramidal side effects may occur with stiffness and rigidity. Should not be given to patients with EP as it lowers the seizure threshold.

Oxygen (Oxygen)

Nausea secondary to hypoxia.

Dosage: In nasal cavities 2 l/min or in respiratory system 5 l/min.

Standard dose: 2 l/min in nose catheters at PONV.

Caution: Caution in respiratory insufficiency (advanced COPD) and hypoventilation.

Table 1. The time a gas bottle with oxygen (bomb) lasts at different flows and pressures.
Size of each bottlePressure (bar)2 l/min3 l/min5 l/min10 l/min
1 litre2001 hour 40 min1 hour 30 min20 min
1501 hour 15 min50 min30 min15 min
10050 min33 min20 min10 min
5025 min17 min10 min5 min
2,5 litres2004 hours 10 min2 hours 45 min1 hour 40 min50 min
1503 hours 2 hours 1 hour 15 min38 min
1002 hours1 hour 20 min50 min25 min
501 hour 50 min25 min13 min
5 litres2008 hours 20 min5 hours 30 min3 hours 20 min1 hour 40 min
1506 hours 15 min4 hours 10 min2 hours 30 min1 hour 15 min
1004 hours 20 min2 hours 45 min1 hours 40 min38 min
502 hours 1 hour 20 min50 min25 min

Ondansetron (Zofran®)

Serotonin antagonist, antiemetic drug.

Dosage: 4-8 mg iv as prophylaxis (8 mg most effective dose), 2 mg/ml solution = 2-4 ml.

Standard dose: 4 mg x 2 i v at PONV.

Caution: Not for children under 2 years. Previous reactions to selective serotonin antagonists.