Post-operative nausea and vomiting (PONV) is one of the most common causes of patient dissatisfaction after anaesthesia, with reported incidence of 30% overall and up to 80% in high-risk patients ^[1]. In preoperative surveys it is regularly rated as the anaesthesia outcome the patients would most like to avoid, more important than postoperative pain ^[2]. PONV may potentially lead to complications such as wound dehiscence, dehydration, electrolyte imbalance, pulmonary aspiration, oesophageal rupture, increased intracranial pressure, pneumothorax, delay in post-operative recovery and discharge from the hospital. In the recent Trust audit, PONV was found to be the main cause of unplanned overnight stay of day surgery patients.

Recently, post-discharge nausea and vomiting (PDNV) after same-day surgery has been recognised as an important entity, as it presents a significant risk to discharged patients who, by definition, no longer have access to fast-onset iv antiemetics or monitored care ^[3]. It happens in 37% of adult patients who undergo general anaesthesia for same-day surgery ^[4].

Risk of PONV/PDNV may be reduced by mandatory pre-operative risk assessment, reducing baseline risk and targeted prophylaxis.

• To standardise risk assessment, prophylaxis and treatment of PONV in adults across Frimley Health NHS Foundation Trust in line with available evidence and international guidelines,

• To reduce the incidence and severity of PONV across the Trust.

For the purpose of this guideline, PONV and PDNV are considered to be essentially the same condition and are further referred to as PONV.

All patients undergoing anaesthesia for surgical or invasive medical procedures should have their PONV risk assessed and documented (excluding local anaesthesia). Patient risk factors, type of surgery and mode of anaesthesia should be taken into account.

Patient factors of post-operative nausea and vomiting (PONV), per Apfel et al ^[5].

*The following patient groups should also be considered as high risk for PONV:

• If any opioid, other than remifentanil, is used by any route (including spinal and epidural). Post-operative opioids are more likely to cause PONV than opioids administered intra-operatively.

• Emetogenic procedures, e.g., laparoscopic and gynaecological surgery, some ENT procedures and strabismus surgery.

• Patients having procedures where it would be dangerous for them to vomit (e.g. after gastric and oesophageal surgery).

5.1. Reducing the baseline risk

Reducing baseline risk factors can significantly decrease the incidence of PONV ^[3]. To reduce risk, always consider:

• Avoiding general anaesthesia and using regional or local anaesthesia

• Using propofol for induction and maintenance of anaesthesia

• Avoiding nitrous oxide (in surgery lasting >1 hour)

• Avoiding volatile anaesthetics

• Minimising the use of intra-operative and post-operative opioids

• Adequate hydration

5.2. Pre-operative prophylaxis

Pre-operative prophylaxis should be considered in patients with high risk of PONV.

5.3. Intra-operative prophylaxis

• Choice of intervention is made by an anaesthetist on individual patient basis, e.g., taking possible side-effects and contra-indications into consideration.

• Combination therapy for PONV prophylaxis is more effective than using a single drug alone. The effects of antiemetics acting on different receptors are additive. When used in combination, drugs from different classes should be selected to optimize their effects.

• The following medications have been shown to reduce risk of PONV. The recommendations are evidence-based and some may not be licensed for PONV ^[3].

4. P6 Acupressure

Stimulation of the P6, (also known as Nei Guan), acupuncture point may be effective for PONV prophylaxis for clinicians familiar with this technique. It was found to be as effective as the commonly used antiemetics for prevention of PONV ^[6] and may be applied either before or after induction of anaesthesia. The P6 point may be stimulated using a variety of techniques, including finger massage and neuromuscular stimulation. Neuromuscular stimulation over the median nerve, used for intra-operative monitoring of neuromuscular blockade, may reduce PONV in the early postoperative period, particularly when tetanic stimulation is used ^[7,8]. The risk of side effects of acupressure is low, including skin redness or irritation and, very rarely, nerve damage, bleeding, or skin infection ^[9].

P6 acupressure point location and stimulation technique:

1. Ask the patient to lay his forearm and hand on a flat surface with the palmar aspect facing you.

2. Note the crease at the transition between the wrist and the forearm.

3. Measure three finger-breadths or 5 cm proximally from this crease and position your index finger to mark the site.

4. Ask the patient to flex his wrist, thereby accentuating the palmaris longus tendon. Then move your index finger radially past the palmaris longus tendon and into the groove bounded by the flexor carpi radial tendon. This is the P6 acupressure point.

5. Once the point has been located, apply downward pressure between the two tendons, massaging and stimulating the area for 4-5 seconds.

P6 stimulation has also been shown to help alleviate intractable hiccups ^[10].

Regular assessment for PONV is crucial for early detection. Treatment must be given to all patients with PONV unless the patient refuses treatment or PONV is mild, self-limiting and there is no medical risk from vomiting.

Before offering antiemetics, consider and address medical and surgical causes of PONV:

• Hypoxia

• Hypovolaemia

• Arterial hypotension

• Arterial hypertension

• Hypothermia

• Hyperthermia

• Infection

• Cerebral hypertension

• Bowel obstruction

• Pain

• Poor mouth hygiene

• Foul or upsetting smells in the vicinity of the patient

• Blood draining down the throat

Antiemetics given via the oral route is only reasonable in case of mild to moderate nausea. The parenteral route is recommended for treatment of moderate to severe nausea and vomiting.

Ondansetron is a recommended first-line treatment (5-HT₃ antagonists are the only drugs that have been adequately studied for treating PONV).

If the minimum dosing interval has not been reached, then ensure the antiemetic used for treatment of PONV is from a different pharmacological class than the agent used for prophylaxis (see table below for dosing intervals).

Give IV fluids to prevent dehydration due to vomiting and lack of oral intake.

The following medications are options for the treatment of PONV:

The patient must not be transferred to the ward whilst moderate / severe PONV is still ongoing.

In case of a very high risk of PONV or recurrent PONV, regular anti-emetics should be considered, alongside rescue anti-emetics.

The patient must be re-assessed no later than 30 min after treatment. This must be recorded on their observation chart. Indications for regular antiemetics should be reviewed daily.

The anti-emetics prescribed regularly must be given regularly, unless contra-indicated. Patients should be encouraged not to refuse the medications just because they have no PONV at the time. If the patient continues to experience moderate to severe PONV or experiences unacceptable side effects, alternative anti-emetic should be prescribed.

If opioids are suspected to be a contributing factor, consider the following:

• Reducing the dose of opioids or discontinuing them by optimising paracetamol and NSAIDs use or employing a regional technique.

• Modifying PCA dosing regimen or changing the opioid (for example, changing Morphine PCA to Oxycodone PCA), this should be discussed with an Acute Pain Team or on-call anaesthetist.

Acute dystonic reactions may rarely occur after the administration of cyclizine, metoclopramide, ondansetron and prochlorperazine. They are thought to be due to dopaminergic-cholinergic imbalance in the basal ganglia and characterized by involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures. 

Do not ignore these symptoms – they may be extremely frightening and distressing for the patient.

If acute dystonia is suspected, call a doctor immediately.

The treatment for a dystonic reaction:

• Procyclidine 5 - 10 mg iv or im stat

• Symptoms usually resolve within 5 - 10 minutes but may take up to 30 minutes for symptoms relief.

• Patients may require further doses

• Procyclidine is contra-indicated in gastro-intestinal obstruction.

Once the episode has been treated:

• inform the patient which drug caused the acute dystonia (if known)

• document this in the notes and on the prescription chart

• discontinue the prescription for the offending drug

• this reaction may need to be formally reported to the MHRA through the “Yellow Card” scheme on-line (www.mhra.gov.uk)

1. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology [Internet]. 1999 Jul [cited 2024 Feb 22]; 91:109–18. Available from: https://doi.org/10.1097/00000542-199907000-00018.

2. Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg [Internet]. 1999 Sep [cited 2024 Feb 22]; 89:652-8. Available from: https://journals.lww.com/anesthesia-analgesia/fulltext/1999/09000/which_clinical_anesthesia_outcomes_are_important.22.aspx.

3. Chatterjee S, Rudra A, Sengupta S. Current concepts in the management of postoperative nausea and vomiting. Anesthesiol Res Pract [Internet]. 2011 Nov [cited 2024 Feb 22]; 2011: Article number 748031. Available from: https://doi.org/10.1155%2F2011%2F748031.

4. Gan JG, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS, et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg [Internet]. 2020 Aug [cited 2024 Feb 22]; 131(2):411-448. Available from: https://doi.org/10.1213/ane.0000000000004833

N.B. Erratum published https://doi.org/10.1213/ane.0000000000005245

5. Apfel CC, Philip BK, Cakmakkaya OS, Shilling A, Shi YY, Leslie JB, et al. Who is at risk for post discharge nausea and vomiting after ambulatory surgery? Anesthesiology [Internet]. 2012 Sep [cited 2024 Feb 22]; 117:475–86. Available from: https://doi.org/10.1097/aln.0b013e318267ef31.

6. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology [Internet]. 1999 Sep [cited 2024 Feb 22]; 91:693–700. Available from: https://doi.org/10.1097/00000542-199909000-00022.

7. Lee A, Chan SK, Fan LT. Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev [Internet]. 2015 Nov [cited 2024 Feb 22]; Article number CD003281. Available from: https://doi.org/10.1002/14651858.cd003281.pub4.

8. Arnberger M, Stadelmann K, Alischer P, Ponert R, Melber A, Greif R. Monitoring of neuromuscular blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting. Anesthesiology [Internet]. 2007 Dec [cited 2024 Feb 22]; 107:903–8. Available from: https://doi.org/10.1097/01.anes.0000290617.98058.d9.

9. Kim YH, Kim KS, Lee HJ, Shim JC, Yoon SW. The efficacy of several neuromuscular monitoring modes at the P6 acupuncture point in preventing postoperative nausea and vomiting. Anesth Analg [Internet]. 2011 Apr [cited 2024 Feb 22]; 112:819–23. Available from: https://doi.org/10.1213/ane.0b013e31820f819e.

10. Dune LS, Shiao SY. Metaanalysis of acustimulation effects on postoperative nausea and vomiting in children. Explore (NY) 2006; 2:314-20.

11. Chang CC, Chang ST, Li TY, Chiang SL, Tsai KC, Lin JC. Resolution of intractable hiccups after near-infrared irradiation of relevant acupoints. Am J Med Sci. 2006 Aug; 332(2):93-6..

12. Nottingham University Hospitals NHS Trust. Guideline for the prevention and treatment of Postoperative Nausea and Vomiting (PONV) in adults. 2017 Jun 22

13. Kim EG, Park HJ, Kang H, Choi J, Lee HJ. Antiemetic effect of propofol administered at the end of surgery in laparoscopic assisted vaginal hysterectomy. Korean J Anesthesiol [Internet]. 2014 Mar [cited 2024 Feb 22]; 66(3):210–215. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983417/.

14. Nazar CE, Lacassie HJ, López RA, Muñoz HR. Dexamethasone for postoperative nausea and vomiting prophylaxis: effect on glycaemia in obese patients with impaired glucose tolerance. Eur J Anaesthesiol [Internet]. 2009 Apr [cited 2024 Feb 22]; 26:318–21. Available from: https://doi.org/10.1097/eja.0b013e328319c09b.

15. Hans P, Vanthuyne A, Dewandre PY, Brichant JF, Bonhomme V. Blood glucose concentration profile after 10 mg dexamethasone in non-diabetic and type 2 diabetic patients undergoing abdominal surgery. Br J Anaesth [Internet]. 2006 Aug [cited 2024 Feb 22]; 97:164–70. Available from: https://doi.org/10.1093/bja/ael111.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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