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Post-operative nausea and vomiting (Guidelines)



  • 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.

Last reviewed: 31/10/2022

Next review date: 31/10/2025

Author(s): Acute Pain Team.

Version: 2

Approved By: TAMSG of the ADTC

Reviewer name(s): Louise Reid, Clinical Nurse Specialist, Claire Wright Acute Pain Nurse Specialist .

Document Id: TAM107

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