Aim for zero: prevention of postoperative nausea and vomiting using an off-patent five-drug multimodal approach.

Editor—We reviewed the recent statement by the International Society for Perioperative Care of the Patient with Obesity (ISPCPO) and the American Society for Metabolic and Bariatric Surgery (ASMBS) 1 Schumann R. Ziemann-Gimmel P. Sultana A. et al. Postoperative nausea and vomiting in bariatric surgery: a position statement endorsed by the ASMBS and the ISPCOP. Surg Obes Relat Dis. 2021; 17: 1829-1833 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar regarding the Fourth Postoperative Nausea/Vomiting (PONV) Consensus Guidelines from 2020. 2 Gan T.J. Belani K.G. Bergese S. et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2020; 131: 411-448 Crossref PubMed Scopus (302) Google Scholar ISPCPO/ASMBS recommended administering at least two or three antiemetics from different pharmacologic categories ‘even in the absence of … risk factors.’ However, one of ISPCPO/ASMBS-recommended drugs, transdermal scopolamine, is not supported by a recent Cochrane Review, 3 Weibel S. Rücker G. Eberhart L.H. et al. Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: a network meta-analysis. Cochrane Database Syst Rev. 2020; 10: CD012859 PubMed Google Scholar as combination of scopolamine and antidopaminergic antiemetics, or combination of scopolamine and aprepitant, could reduce efficacy of both agents. Meanwhile, recent loss of patent protection for aprepitant and palonosetron has led our centre to ‘Aim for Zero’, and apply routine five-drug prophylaxis regardless of consensus 2 Gan T.J. Belani K.G. Bergese S. et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2020; 131: 411-448 Crossref PubMed Scopus (302) Google Scholar -guided risk factors. In 2021, we began using intrathecal morphine for bariatric and other general surgery procedures otherwise performed under general anaesthesia. These patients received palonosetron 75 μg i. v. as part of a five-drug plan that also included 4–8 mg perphenazine p. o., aprepitant 40 mg p. o., diphenhydramine 12.5 mg i. v., and dexamethasone 4 mg i. v. Use of this regimen for patients undergoing general anaesthesia began after notification of peer-reviewed manuscript acceptance 4 Williams B.A. Ibinson J.W. Cellurale M. Nalepka T. Becker D.B. Same-day and next-day pain and nausea parameters after intrathecal morphine for abdominal panniculectomy and mastectomy post-bariatric surgery. Pain Med. 2021; 22: 3114-3116 Crossref PubMed Scopus (3) Google Scholar of a case report and case series related to successful five-drug prophylaxis associated with intrathecal morphine (with local anaesthetic bupivacaine or tetracaine) use for total joint replacement (TJR) under spinal anaesthesia. The impetus for improvement was also motivated by a recent report indicating an unacceptably high 44% incidence of PONV on postoperative Day 0 (POD0) and 1 (POD1) after colorectal surgery in an enhanced recovery pathway including intrathecal morphine including three antiemetics (ondansetron, dexamethasone, and either the patent-protected aprepitant or off-patent perphenazine). 5 Holder-Murray J. Esper S.A. Boisen M.L. et al. Postoperative nausea and vomiting in patients undergoing colorectal surgery within an institutional enhanced recovery after surgery protocol: comparison of two prophylactic antiemetic regimens. Korean J Anesthesiol. 2019; 72: 344-350 Crossref PubMed Scopus (9) Google Scholar We opted for a novel strategy of pan-prophylaxis against all available emetogenic mechanisms regardless of risk factors before any emetogenic stimuli were experienced, including preoperative intrathecal morphine given in a separate location outside the operating room. 6 Williams B.A. Kentor M.L. Williams J.P. et al. Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology. 2000; 93: 529-538 Crossref PubMed Google Scholar Postoperative nausea and vomiting: is the big little problem becoming a smaller little problem?British Journal of AnaesthesiaVol. 131Issue 1PreviewPostoperative nausea and vomiting (PONV) has been identified as a big (very frequently encountered) little (not linked to life-threatening outcomes) problem. Traditional drugs (dexamethasone, droperidol or similar drugs, serotonin receptor antagonists) each have significant but limited effect, leading to an increasing use of combination therapies. High-risk patients, often identified through use of risk scoring systems, remain with a significant residual risk despite combining up to three traditional drugs. Full-Text PDF