Rescue Treatment of Postoperative Nausea and Vomiting

A Systematic Review of Current Clinical Evidence

Tong J. Gan, MD, MBA, MHS, FRCA; Zhaosheng Jin, MBBS; Tricia A. Meyer, PharmD, MS, FASHP, FTSHP

Disclosures

Anesth Analg. 2022;135(5):986-1000. 

In This Article

Abstract and Introduction

Abstract

Although prophylactic antiemetics are commonly used perioperatively, an estimated 30% of surgical patients still suffer from postoperative nausea and vomiting (PONV). Very few prospective trials have studied rescue treatment of PONV after failure of prophylaxis, providing limited evidence to support clinical management. In patients who have failed PONV prophylaxis, administering a rescue antiemetic from the same drug class has been reported to be ineffective. For many antiemetics currently used in PONV rescue, significant uncertainty remains around the effective dose range, speed of onset, duration of effect, safety, and overall risk-benefit ratio. As prompt, effective PONV rescue after failure of prophylaxis is important to optimize postoperative recovery and resource utilization, we conduct this systematic review to summarize the current evidence available on the topic.

Introduction

Despite the availability of a number of antiemetics in several therapeutic classes, the management of postoperative nausea and vomiting (PONV), estimated to affect 15% to 30% of all surgical patients,[1] remains a challenge. This is particularly the case for the treatment of patients with established PONV despite receiving 1 or more prophylactic interventions. While there are thousands of PONV prophylaxis trials in the literature, there are few trials on rescue treatment and extremely few in the context of failed PONV prophylaxis. This means there is very little evidence-based guidance for the management of most patients with active PONV, given that the large majority of surgical patients currently do receive at least 1 prophylactic antiemetic preoperatively or perioperatively.[2]

It has been reported that redosing the same antiemetic, or even one of the same class, that was used unsuccessfully for prophylaxis is not more effective than use of placebo.[3–6] However, this only tells clinicians what not to do, and there is far less evidence about what should be done, especially given the appreciable placebo success rate observed in the treatment of established PONV.[3,7,8]

Due to the relative lack of high-grade evidence, one approach has been to assume that an agent that works in prophylaxis is likely to be effective in treatment. In doing so, one runs the risk of overlooking several pharmacokinetic and pharmacodynamic considerations, which are different between prophylaxis and rescue treatment, including the optimal dosage, speed of onset, duration of effect, route of administration, tolerability, and overall risk-benefit ratio. In this systematic review, we discuss and summarize currently available evidence on pharmacological and nonpharmacological approaches to PONV rescue treatment.

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