Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting

Tong J. Gan, MD, MBA, MHS, FRCA; Kumar G. Belani, MBBS, MS; Sergio Bergese, MD; Frances Chung, MBBS; Pierre Diemunsch, MD, PhD; Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA; Zhaosheng Jin, MBBS, BSc; Anthony L. Kovac, MD; Tricia A. Meyer, PharmD, MS, FASHP, FTSHP; Richard D. Urman, MD, MBA; Christian C. Apfel, MD, PhD; Sabry Ayad, MD, MBA, FASA; Linda Beagley, MS, RN, CPAN, FASPAN; Keith Candiotti, MD; Marina Englesakis, BA (Hons), MLIS; Traci L. Hedrick, MD, MSc; Peter Kranke, MD, MBA; Samuel Lee, CAA; Daniel Lipman, DNP, CRNA; Harold S. Minkowitz, MD; John Morton, MD, MPH, MHA; Beverly K. Philip, MD


Anesth Analg. 2020;131(2):411-448. 

In This Article

Abstract and Introduction


This consensus statement presents a comprehensive and evidence-based set of guidelines for the care of postoperative nausea and vomiting (PONV) in both adult and pediatric populations. The guidelines are established by an international panel of experts under the auspices of the American Society of Enhanced Recovery and Society for Ambulatory Anesthesia based on a comprehensive search and review of literature up to September 2019. The guidelines provide recommendation on identifying high-risk patients, managing baseline PONV risks, choices for prophylaxis, and rescue treatment of PONV as well as recommendations for the institutional implementation of a PONV protocol. In addition, the current guidelines focus on the evidence for newer drugs (eg, second-generation 5-hydroxytryptamine 3 [5-HT3] receptor antagonists, neurokinin 1 (NK1) receptor antagonists, and dopamine antagonists), discussion regarding the use of general multimodal PONV prophylaxis, and PONV management as part of enhanced recovery pathways. This set of guidelines have been endorsed by 23 professional societies and organizations from different disciplines (Appendix 1).

What Other Guidelines Are Available on This Topic? Guidelines currently available include the 3 iterations of the consensus guideline we previously published, which was last updated 6 years ago;[1–3] a guideline published by American Society of Health System Pharmacists in 1999;[4] a brief discussion on PONV management as part of a comprehensive postoperative care guidelines;[5] focused guidelines published by the Society of Obstetricians and Gynecologists of Canada,[6] the Association of Paediatric Anaesthetists of Great Britain & Ireland[7] and the Association of Perianesthesia Nursing;[8] and several guidelines published in other languages.[9–12]

Why Was This Guideline Developed? The current guideline was developed to provide perioperative practitioners with a comprehensive and up-to-date, evidence-based guidance on the risk stratification, prevention, and treatment of PONV in both adults and children. The guideline also provides guidance on the management of PONV within enhanced recovery pathways.

How Does This Guideline Differ From Existing Guidelines? The previous consensus guideline was published 6 years ago with a literature search updated to October 2011. Several guidelines, which have been published since, are either limited to a specific populations[7] or do not address all aspects of PONV management.[13] The current guideline was developed based on a systematic review of the literature published up through September 2019. This includes recent studies of newer pharmacological agents such as the second-generation 5-hydroxytryptamine 3 (5-HT3) receptor antagonists, a dopamine antagonist, neurokinin 1 (NK1) receptor antagonists as well as several novel combination therapies. In addition, it also contains an evidence-based discussion on the management of PONV in enhanced recovery pathways. We have also discussed the implementation of a general multimodal PONV prophylaxis in all at-risk surgical patients based on the consensus of the expert panel.


Nausea and vomiting are two of the most common adverse events in the postoperative period with an estimated incidence of 30% in the general surgical population and as high as 80% in high risk cohorts.[14] This can be a highly distressing experience and is associated with significant patient dissatisfaction.[15,16] In addition, the occurrence of postoperative nausea and vomiting (PONV) is also associated with a significantly longer stay in the postanesthesia care unit (PACU),[17] unanticipated hospital admission,[18] and increased health care costs.[19]

Optimal management of PONV is a complex process. There are numerous antiemetics with varying pharmacokinetics, efficacy, and side-effect profiles, thus the choice of an antiemetic will depend on the clinical context. The benefit of PONV prophylaxis also needs to be balanced with the risk of adverse effects. At an institutional level, the management of PONV is also influenced by factors such as cost-effectiveness, drug availability, and drug formulary decisions. While there are several published guidelines on the management of PONV, they are limited to specific patient populations,[6,7] do not address all aspects of PONV management in sufficient detail,[5,13] or are not up to date with current literature.

Our group has previously published 3 iterations of the PONV consensus guideline in 2003, 2009, and 2014,[1–3] with the aim of providing comprehensive, evidence-based clinical recommendations on the management of a PONV in adults and children. A systematic literature search identified over 9000 published studies since the last consensus guideline (literature search up to October 2011). In addition, the establishment of enhanced recovery pathways (ERPs) has led to a significant paradigm shift in the approaches to perioperative care. We therefore present this update to incorporate the findings of the most recent studies into our recommendations.