Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting

Adapted with permission from the American Society of Anesthesiologists Task Force on Acute Pain Management, "Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management," Anesthesiology, 2012;116:248–273.^25
aStatistical significance level was set at P < .05.

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; PONV, postoperative nausea and vomiting.
^aUse of nitrous oxide over 1 h duration.

Abbreviation: GA, general anesthesia.

These recommendations are evidence-based and not all the drugs have an FDA indication for PONV. Drugs are listed alphabetically.
Abbreviations: FDA, Food and Drug Administration; IM, intramuscular; IV, intravenous(ly); ODT, orally disintegrated tablet; PO, per os; PONV, postoperative nausea and vomiting.^aSee FDA Black box warning.
^aSee FDA Black box warning.

Abbreviation: 5-HT₃, 5-hydroxytryptamine 3.

These recommendations are evidence-based and not all the drugs have an
FDA indication for PONV. Drugs are listed alphabetically.
Abbreviations: FDA, Food and Drug Administration; PONV, postoperative
nausea and vomiting; POV, postoperative vomiting.
^aSee FDA black box warning. Recommended doses 10–15 μg/kg.
^bApproved for POV in pediatric patients aged ≥1 mo.

Authors and Disclosures

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**** and Beverly K. Philip, MD††††

*Department of Anesthesiology, Stony Brook Renaissance School of Medicine, Stony Brook, New York; †Department of Anesthesiology, M Health Fairview, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; ‡Department of Anesthesiology and Neurological Surgery, Stony Brook Renaissance School of Medicine, Stony Brook, New York; §Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; ||Department of Anaesthesia and Surgical Resuscitation, University of Strasbourg, Strasbourg, Special Article France; ¶Department of the Anaesthesia and Intensive Care, University Hospitals of Hautepierre and CMCO, Strasbourg, France; #Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina; **Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas; ††Department of Pharmacy, Baylor Scott & White Health-Temple Medical Center, Temple, Texas; ‡‡Department of Anesthesiology, Texas A&M College of Medicine, Bryan, Texas; §§Department of Epidemiology & Biostatistics, University of California San Francisco Medical Center, San Francisco, California; ||||Department of Anesthesiology, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; ¶¶Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; ##Department of Nursing Education, Swedish Hospital Part of NorthShore, Chicago, Illinois; ***Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, Florida; †††Library & Information Services, University Health Network, Toronto, Ontario, Canada; ‡‡‡Department of Surgery, University of Virginia Health System, Charlottesville, Virginia; §§§Department of Anaesthesia, University Hospital of Wuerzburg, Würzburg, Germany; ||||||Department of Anesthesiology, University of Colorado Hospital, Aurora, Colorado; ¶¶¶Department of Anesthesiology, MD Anderson Cancer Center, Houston, Texas; ###Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; ****Department of Surgery, Yale School of Medicine, New Haven, Connecticut; and ††††Department of Anesthesiology, and Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.

Address correspondence to
Tong J. Gan, MD, MBA, MHS, FRCA, Department of Anesthesiology, Stony Brook Renaissance School of Medicine, Stony Brook, NY 11794. Address e-mail to tong.gan@stonybrookmedicine.edu.

Conflicts of Interest
See Disclosures at the end of the article.

Disclosures
Name: Tong J. Gan, MD, MBA, MHS, FRCA.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: T. J. Gan received honoraria from Acacia, Edwards, Masimo, Medtronic, Merck, and Mallinckrodt. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Kumar G. Belani, MBBS, MS.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Sergio Bergese, MD.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: S. Bergese received funding from Acacia for a previous Clinical Trial in Ohio State University. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Frances Chung, MBBS.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: F. Chung has received research support from the Ontario Ministry of Health and Long-Term Care, University Health Network Foundation, Acacia Pharma, Medtronics grants to institution outside of the submitted work, up-to-date royalties, STOP-Bang proprietary to University Health Network. Speaker honorarium from Baxter Pharma. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Pierre Diemunsch, MD, PhD.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: P. Diemunsch is a member of the advisor panel on airway management for Ambu, received research and conference funding from Fisher & Paykel, received research grants from Acacia Pharma, is a member of the ERAS advisory panel for MSD, is an expert at the Court of Appeal for the French Government. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: A. S. Habib conducted funded research for Pacira Biosciences, Avanos Medical Inc, and is a member of the advisory board for Takeda. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Zhaosheng Jin, MBBS, BSc.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Anthony L. Kovac, MD.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: A. L. Kovac serves as a member of the speaker's bureau for Merck, Helsinn, Mundipharma, and Acacia. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Tricia A. Meyer, PharmD, MS, FASHP, FTSHP.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: T. A. Meyer received funding from Acacia and Neumentum. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Richard D. Urman, MD, MBA.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: R. D. Urman received research funding from Merck; consulting fees and research funding from Medtronic; consulting fees from Takeda; consulting fees and research funding from Acacia; and consulting fees from Posimir. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Christian C. Apfel, MD, PhD.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Sabry Ayad, MD, MBA, FASA.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: S. Ayad received funding from Pacira, Medtronic, and Acacia. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Linda Beagley, MS, RN, CPAN, FASPAN.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Keith Candiotti, MD.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: K. Candiotti is a consultant and received research support from Acacia, Pfizer, and Takeda. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Marina Englesakis, BA (Hons), MLIS.
Contribution: This author helped with the formal literature search, conception, design, and writing of the manuscript.
Conflicts of Interest: The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Traci L. Hedrick, MD, MSc.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: T. L. Hedrick received funding from MedEdicus. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Peter Kranke, MD, MBA.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: P. Kranke acted as investigator in phase III trials on amisulpride during the last 3 years. He gave invited lectures for FreseniusKabi (propofol), Grünenthal, CSL-Behring, and TevaRatiopharm. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Samuel Lee, CAA.
Contribution: This author contributed to the conception, design, and writing of the manuscript.
Conflicts of Interest: The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Daniel Lipman, DNP, CRNA.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Harold S. Minkowitz, MD.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: H. S. Minkowitz received funding from Acacia, AcelRX, Adynxx, Concentric, Durect, Heron, Merck, Mallinckrodt, Innocoll, Pacira, Neumentum, Westward, Trevena, and Takeda. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: John Morton, MD, MPH, MHA.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: J. Morton received funding from Medtronic, Olympus, and Novo Nordisk. The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
Name: Beverly K. Philip, MD.
Contribution: This author helped with the conception, design, and writing of the manuscript.
Conflicts of Interest: The faculty received reimbursement for travel expenses attending the meeting. No honorarium was provided.
This manuscript was handled by: Jean-Francois Pittet, MD.

Appendix 1: Professional Society Endorsements

This set of guidelines have been officially endorsed by the following professional organizations:

• American Society for Enhanced Recovery

• American Society of Health Systems Pharmacists

• American Society of Peri Anesthesia Nurses

• American Society of Anesthesiologists

• American Academy of Anesthesiologist Assistants

• American Association of Nurse Anesthetists

• American College of Clinical Pharmacy

• American College of Clinical Pharmacy Perioperative Care Practice and Research Network

• Australian Society of Anesthetists

• Brazilian Society of Anesthesiology

• Chinese Society of Anesthesiology

• European Society of Anesthesiology

• Indian Society of Anesthesiologists

• Japanese Society of Anesthesiologists

• Korean Society of Anesthesiologists

• Malaysian Society of Anesthesiologists

• Royal College of Anesthesiologist Thailand

• Singapore Society of Anesthesiologists

• Society for Ambulatory Anesthesia

• Society of American Gastrointestinal and Endoscopic Surgeons

• Society for Pediatric Anesthesia

• South African Society of Anesthesiologists

• Taiwan Society of Anesthesiologists