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Special Article E SPECIAL ARTICLE 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,**** and Beverly K. Philip, MD†††† onoddfo tp/junl.w.o/nshsaaagsab hM5PKHTIqnGFMeXQvO6RKViRBa0Uv4xto 07/14/2020 on BhDMf5ePHKbH4TTImqenVGPFTMFeRXdQfvvOj6CRiKaVficRIB6au0YUNvT4sxTt by http://journals.lww.com/anesthesia-analgesia from Downloaded This consensus statement presents a comprehensive and evidence-based set of guidelines for Downloaded from http://journals.lww.com/anesthesia-analgesia by BhDMf5ePHKbH4TTImqenVGPFTMFeRXdQfvvOj6CRiKaVficRIB6au0YUNvT4sxTt on 07/14/2020 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 pro- tocol. In addition, the current guidelines focus on the evidence for newer drugs (eg, second-gener- ation 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 ago1–3; a guideline published by American Society of Health System Pharmacists in 19994; a brief discussion on PONV management as part of a comprehensive postoperative care guidelines5; focused guidelines published by the Society of Obstetricians and Gynecologists of Canada,6 the Association of Paediatric Anaesthetists of Great Britain & Ireland7 and the Association of Perianesthesia Nursing8; 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 populations7 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 addi- tion, 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. (Anesth Analg XXX;XXX:00–00) From the *Department of Anesthesiology, Stony Brook Renaissance School of France; ¶Department of the Anaesthesia and Intensive Care, University Medicine, Stony Brook, New York; †Department of Anesthesiology, M Health Hospitals of Hautepierre and CMCO, Strasbourg, France; #Department Fairview, Masonic Children’s Hospital, University of Minnesota, Minneapolis, of Anesthesiology, Duke University School of Medicine, Durham, North Minnesota; ‡Department of Anesthesiology and Neurological Surgery, Stony Carolina; **Department of Anesthesiology, University of Kansas Medical Brook Renaissance School of Medicine, Stony Brook, New York; §Department Center, Kansas City, Kansas; ††Department of Pharmacy, Baylor Scott & of Anesthesia and Pain Management, Toronto Western Hospital, University White Health-Temple Medical Center, Temple, Texas; ‡‡Department of Health Network, University of Toronto, Ontario, Canada; ║Department of Anesthesiology, Texas A&M College of Medicine, Bryan, Texas; §§Department Anaesthesia and Surgical Resuscitation, University of Strasbourg, Strasbourg, of Epidemiology & Biostatistics, University of California San Francisco Copyright © 2020 International Anesthesia Research Society Medical Center, San Francisco, California; ║║Department of Anesthesiology, DOI: 10.1213/ANE.0000000000004833 Cleveland Clinic Lerner College of Medicine, Case Western Reserve XXX XXX • Volume XXX • Number XXX www.anesthesia-analgesia.org 1 Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. Management of Postoperative Nausea and Vomiting GLOSSARY 5-HT3 = 5-hydroxytryptamine 3; AQI = Anesthesiology Quality Institute; ARR = absolute risk reduction; ASA = American Society of Anesthesiologists; ASER = American Society for Enhanced Recovery; BMI = body mass index; BP = blood pressure; CD = cesarean delivery; CER = control event rate; CI = confidence interval; CINV = chemotherapy-induced nausea and vomiting; CMS = Centers for Medicare & Medicaid Services; CNS = central nervous system; ERPs = enhanced recovery path- ways; FDA = Food and Drug Administration; GA = general anesthesia; GABA = γ-aminobutyric acid; GI = gastrointestinal; HR = heart rate; IM = intramuscular; ISMP = Institute of Safe Medication Practices; IV = intravenous(ly); LOS = length of stay; MECIR = Methodological Expectations of Cochrane Intervention Review; MIPS = merit-based incentive payment system; NACOR = National Anesthesia Clinical Outcomes Registry; NK1 = neurokinin 1; NNH = number needed to harm; NNT = number needed to treat; NPO = nil per os; NSAIDs = nonsteroidal anti-inflammatory drugs; ODT = orally disintegrated tablet; PACU = postanesthesia care unit; PC6 = pericardium 6 acupuncture point; PCA = patient-controlled analgesia; PDNV = postdischarge nausea and vomiting; PECs = pectoral nerves block; PO = per os; POD = postoperative day; PONV = postoperative nausea and vomiting; POV = postoperative vomiting; POVOC = Postoperative Vomiting in Children score; PRESS = Peer Review of Electronic Search Strategies; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-analyses; PVB = paravertebral block; RA = regional anesthesia; RCT = random- ized controlled trials; RRR = relative risk reduction; SRMA = systematic review and meta-analysis; TAP = transversus abdominis plane block; TIVA = total intravenous anesthesia ausea and vomiting are two of the most com- pharmacokinetics, efficacy, and side-effect profiles, mon adverse events in the postoperative thus the choice of an antiemetic will depend on the Nperiod with an estimated incidence of 30% in clinical context. The benefit of PONV prophylaxis also the general surgical population and as high as 80% needs to be balanced with the risk of adverse effects. in high risk cohorts.14 This can be a highly distress- At an institutional level, the management of PONV ing experience and is associated with significant is also influenced by factors such as cost-effective- patient dissatisfaction.15,16 In addition, the occurrence ness, drug availability, and drug formulary decisions. of postoperative nausea and vomiting (PONV) is also While there are several published guidelines on the associated with a significantly longer stay in the post- management of PONV, they are limited to specific anesthesia care unit (PACU),17 unanticipated hospital patient populations,6,7 do not address all aspects of admission,18 and increased health care costs.19 PONV management in sufficient detail,5,13 or are not Optimal management of PONV is a complex pro- up to date with current literature. cess. There are numerous antiemetics with varying Our group has previously published 3 iterations of the PONV consensus guideline in 2003, 2009, and 2014,1–3 with the aim of providing comprehen- University, Cleveland, Ohio; ¶¶Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; ##Department of Nursing Education, Swedish Hospital sive, evidence-based clinical recommendations on Part of NorthShore, Chicago, Illinois; ***Department of Anesthesiology, the management of a PONV in adults and children. Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, Florida; †††Library & Information Services, A systematic literature search identified
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