Practice Perfect 654
Nausea and Vomiting: Prevention and Treatment Post-Operatively

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Jarrod Shapiro, DPM, FACFAS, FACPM, FFPM, RCPS Glasg

Practice Perfect May 14, 2019

Last week we talked about the back end of things - postoperative constipation and the fact that docusate is no longer recommended due to its lack of effectiveness – so this week, I just can’t help but bring up the front end: nausea and vomiting.

I know what you’re thinking. “This guy has gone nuts, talking first about poop and now vomit. What happened to podiatry?” But as much as I’d love to ignore these twin topics, it’s the “accessory” symptoms that often cause patients the most grief: pain, poop, and projection – so to speak. As someone who is particularly prone to nausea, I can appreciate when this issue spews forth.

It’s the “accessory” symptoms that often cause patients the most grief: pain, poop, and projection

Here’s a quick, high-yield review of the subject with recommendations to help your postoperative patients maintain comfort and equilibrium. The information below is from the combined work of Gan.^1,2

Emesis – It’s (Almost) All in the Head

The brainstem contains a poorly defined area, the “vomiting center,” which is a central pattern generator that leads to vomiting. It receives input from – lucky us – several areas, including the cortex, cerebellum, and vestibular apparatus, as well as the vagus and glossopharyngeal nerves. There are also receptors in the cerebrospinal fluid and blood. These various areas of input explain why nausea and vomiting are such common side effects. Emesis is mediated by various neurotransmitters including serotonin, dopamine, histamine, neurokinin, and cholinergic ones as well. Treatment aims to block these neurotransmitters.

Who’s at Risk

Female gender
History of motion sickness or postop nausea
Nonsmokers
Use of perioperative opioids
Use of volatile anesthetics

Treatment Options for Postoperative Emesis (with Comments)

Serotonin (5-HT3 receptor) Antagonists

Ondansetron (Zofran^®) 4mg IV (4-8mg PO) and dolasetron (Anzemet^®) 50-100mg PO are the current cornerstones of treatment due to improved efficacy and well-tolerated side effects (headache, dizziness, constipation, and diarrhea). These are most effective when given at the end of surgery.

Palonosetron (Aloxi^®) is the newest 5HT3 receptor blocker, and is most commonly used for chemotherapy-induced nausea. Available only as an IV formulation (0.075mg/24 hours), this medication has a longer duration of action (40 hours) than the others due to its tighter receptor binding.

Cholinergic Antagonists

Transdermal scopolamine patches – release 1.5mg over 3 days. Can cause visual disturbances, dry mouth, and dizziness. Highly useful as an adjunct to other antiemetics.

Steroids

Dexamethasone 4-5mg IV at anesthesia induction is effective in prevention of postop nausea and vomiting.

Available Credits: CPME 0

Propofol – Mechanism of antiemesis is unclear but has been found to be effective when given at induction of anesthesia. Recommended to use as inductive and maintenance medication during anesthesia to reduce postoperative emesis.

Phenothiazines – No longer recommended as first line therapy due to high rate of side effects. Ex promethazine (Phenergan^®) 25-50mg.

Benzamines

Metoclopramide (Reglan^®) 10mg IV best for adults. No longer recommended as an antiemetic due to poor effectiveness.

The most recent antiemetic to hit the United States is aprepitant (Emend^®), which is a substance P antagonist working via blockade of the neurokinin 1 (NK1) receptor. With a 40-hour half-life, aprepitant is indicated for emesis associated with chemotherapy and is dosed at 40mg as a one-time therapy preoperatively and 125mg PO on day one followed by 80mg PO in the AM for 2 more days during a 3-day regimen.

Bringing it Up Again…

Based on this information, the best preventative treatment would be to keep patients well hydrated preoperatively, use propofol for induction and maintenance of anesthesia, and give a dose of dexamethasone 4mg at induction for those with a history of perioperative nausea. Ondansetron and dolasetron remain excellent choices for postoperative nausea, and we should stay away from Phenergan and Reglan. For those patients with very severe nausea and vomiting one might consider a preoperative transdermal scopalamine patch (if a history is known) or even the off-label use of oral aprepitant. I hope your patients remain vomit free!

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References

Gan TJ, Diemunsch P, Abib HS, et al. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2014 Jan;118(1):85-113.
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Le TP, Gan TJ. Update on the Management of Postoperative Nausea and Vomiting and Postdischarge Nausea and Vomiting in Ambulatory Surgery. Anesthesiol Clin. 2010 Jun;28(2):225-249.
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