Post-operative nausea and vomiting (Guidelines)
TAM (Treatments and Medicines) NHS Highland
Warning
What's new / Latest updates
Please note that intramuscular administration of anti-emetics has been removed from this guideline
Audience
- Argyll & Bute HSCP and Highland HSCP
- Secondary Care
General Management
- Ensure adequate pain control, warmth and comfort
- Correct hypotension, hypovolaemia and hypoxia
- Ensure adequate hydration of the patient
- Ensure that the stomach is not full. A naso-gastric tube may be required. If one is present aspirate it
- For high risk patients, consider regular anti-emetics for the first 24 hours postoperatively.
- If nausea or vomiting persists, add in a second drug from a different group
High Risk Patients
- History of motion sickness.
- Females of reproductive years.
- Previous history of PONV.
- Patients receiving Opioids.
- After certain operations i.e. Gynaecology, ENT, Ophthalmology.
- Very anxious patients.
Anti-ememtic groups
| First Line | Second line | Third line | Rescue |
| 5HT3 Receptor antagonist | Antihistamine | Phenothiazine | Steroid |
| Ondansetron | Cyclizine | Prochlorperazine | Dexamethasone |
| 4mg IV every 8 hours 8mg oral every 12 hours | 50mg IV/oral every 8 hours | 12.5mg every 8 hours 3 to 6mgs buccal every 12 hours |
6.6mg IV as a single dose |
Check BNF for contra-indications and side-effects
- Ondansetron should always be the first agent of choice.
- Metoclopramide has not been demonstrated to be useful in PONV. It does not have pro-kinetic effects in the presence of opioids and is contraindicated after bowel surgery.
- Prochlorperazine and cyclizine should not be used together as they have similar side-effects.
- Caution with cyclizine in the elderly. Consider reducing dose to 25mg.
- Dexamethasone is useful for resistant cases.
- Buccastem® (buccal prochlorperazine) is useful as intramuscular injections can then be avoided.