Prevention of Postoperative Nausea and Vomiting in High-Risk Patients

Abstract

Introduction: Postoperative nausea and vomiting (PONV) remains common despite antiemetics. Multimodal prophylaxis is recommended, but optimal drug combinations and non-pharmacological adjuncts are debated.
Methods: This literature review (2015–2024) included RCTs and network meta-analyses on adults with ≥2 Apfel risk factors undergoing general anesthesia. Interventions: 5-HT3 antagonists, NK1 antagonists, dexamethasone, droperidol, and acustimulation. Outcome: complete response (no PONV at 24 hours).
Results: Forty-one studies (n=15,230) showed complete response rates: NK1 antagonist + 5-HT3 antagonist + dexamethasone = 82%; 5-HT3 + dexamethasone = 68%; single agent = 48%. Acustimulation added 5% benefit. Droperidol caused QT prolongation (risk difference 1.8%). No regimen eliminated PONV entirely.
Discussion: Triple therapy (aprepitant/ondansetron/dexamethasone) is most effective but costly. Acustimulation is a low-risk adjunct. Droperidol use should be restricted to monitored settings.
Conclusions: High-risk PONV patients require at least two prophylactic agents from different classes. Triple therapy is justified for very high-risk (Apfel 3–4) cases. Implementation of risk-based protocols is essential.