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Postoperative Nausea and Vomiting : Pediatric
Case Synopsis
A 10-year-old girl with a history of motion sickness is scheduled for adenotonsillectomy. This will be her third surgery under general anesthesia. She had multiple episodes of postoperative nausea and vomiting (PONV) after the two previous procedures (dental rehabilitation and correction of strabismus), despite receiving antiemetic prophylaxis intraoperatively. After the strabismus surgery, she was hospitalized with dehydration caused by refractory postoperative emesis. Her mother gives a similar history of severe PONV after gynecologic surgery. Both the patient and her parents are extremely anxious and ask what can be done to avoid a similar experience.
Acknowledgment
The authors wish to thank Dr. Senthilkumar Sadhasivam for his contribution to the previous edition of this chapter.
Problem Analysis
Recognition
Although postoperative nausea and vomiting (PONV) has been called the big “little problem” in anesthesia, it decreases patient satisfaction with anesthetic care, delays hospital discharge, and may increase costs resulting from unplanned hospital admission. In adults, postoperative nausea occurs in 50%, vomiting in 30%, and postdischarge nausea and vomiting (PDNV) in 37%, with rates as high as 80% for various subsets. Many younger pediatric patients are unable to convey the subjective feeling but indicate that they have the subjective symptoms of nausea. The rate of postoperative vomiting (POV) is therefore used as an endpoint in pediatric studies. The incidence of POV is higher in children than in adults.
PONV is increasingly used as a quality care marker. A revised set of Consensus Guidelines for PONV management was published in 2014. These are listed in Table 203.1 and have been endorsed by many professional anesthesiology associations worldwide. The first recommendation was to assess the individual patient’s risk for PONV based on defined risk factors, followed by the use of various strategies to reduce baseline risks. The guidelines stated that the administration of prophylactic antiemetics for adults and children should be based on the estimated risk for the individual patient, with no prophylaxis for those at lowest risk, one- to two-drug prophylaxis for moderate risk, and multimodal combination therapy (≥2 interventions) for subjects at the highest risk. The recommendation for rescue treatment for established PONV differed for those who had not received prophylaxis versus subjects with a failure of antiemetic prophylaxis. In the latter case, it was recommended that a drug from a class other than that used for prophylaxis be used for rescue therapy. Finally, the guidelines advocated steps to facilitate wider implementation of these recommendations.
TABLE 203.1
Consensus Guidelines for the Management of Postoperative Nausea and Vomiting
Data from Gan TJ, Diemunsch P, Habib AS, et al: Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 118(1):85-113, 2014.
| Guideline No. | Title |
|---|---|
| 1 | Identify patient’s risk for PONV |
| 2 | Reduce baseline risk factors for PONV |
| 3 | Administer PONV prophylaxis using 1–2 interventions in adults at moderate risk for PONV |
| 4 | Administer prophylactic therapy with combination (≥2) interventions/multimodal therapy in patients at high risk for PONV |
| 5 | Administer prophylactic antiemetic therapy to children at increased risk for POV: as in adults, use of combination therapy is most effective |
| 6 | Provide antiemetic treatment to patients with PONV who did not receive prophylaxis or in whom prophylaxis failed |
| 7 | Ensure PONV prevention and treatment is implemented in the clinical setting |
| 8 | Use general multimodal prevention to facilitate implementation of PONV policies |
PONV, Postoperative nausea and vomiting.
Risk Assessment
Although many factors are associated with increased PONV, the Consensus Guidelines focused on those shown to be independent in large cohort studies and not the confounding factors. For example, increased PONV in adults undergoing abdominal surgery may reflect the effect of confounding issues, such as duration of surgery or increased opioid use. Different independent risk factors are used in pediatric and adult risk stratification scores. The most important independent risk factors in adults are female gender, previous history of PONV/motion sickness, postoperative opioid administration, and nonsmoking status, with each factor increasing the relative risk of PONV by approximately 20%. The independent risk factors in children were (1) duration of surgery longer than 30 minutes; (2) age greater than 3 years; (3) prior POV in the patient, parent, or sibling; and (4) strabismus surgery. If 0, 1, 2, 3, or 4 of these factors were present, the patient’s risk for POV was approximately 9%, 10%, 30%, 55%, and 70%, respectively. This score by Eberhart and colleagues was validated in another pediatric patient population.
A new, simpler, 6-point pediatric vomiting in the postoperative period (VPOP) score was obtained from a study of 2392 children and was based on age, predisposition to POV, duration of anesthesia longer than 45 minutes, type of surgery, and use of multiple doses of opioids ( Table 203.2 ). The age-related risk for pediatric POV in children is lowest for those less than 3 years, highest for 6 to 13 years, and intermediate for a group ages 3 to 6 years or greater than 13 years. A predisposition to POV was defined as prior history of POV, motion sickness, or family history of POV. The study also identified tonsillectomy and tympanoplasty in addition to strabismus surgery as independent risk factors. The authors considered patients with a risk score of 0 to 1 as being at low risk, 2 to 3 as moderate, and 4 to 6 as high risk for POV. This new score had a greater area under the receiver operating characteristics curve compared with the earlier score by Eberhart and colleagues, suggesting that the VPOP score could be used to guide management of POV in children.
TABLE 203.2
Clinical Risk Score for Vomiting in the Postoperative Period: The VPOP Score
Modified from Bourdaud N, Devys JM, Bientz J, et al: Development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients: the VPOP score. Pediatr Anesth 24(9):945-952, 2014.
| Point Score | |||
|---|---|---|---|
| 0 | 1 | 2 | |
| Age | Below 3 years | 3–6 years or >13 years | Between 6 and 13 years |
| Predisposition to POV Previous POV, motion sickness, or family history of POV |
No predisposition | Predisposition present | |
| Duration of anesthesia >45 minutes | No | Yes | |
| High-risk surgery (tonsillectomy, tympanoplasty, strabismus) | Not high PONV risk procedures | High PONV risk (tonsillectomy, tympanoplasty, strabismus) | |
| Multiple doses of opioids | No | Yes | |
Low risk: Total score of 0–1. Moderate risk: Total score of 2–3. High risk: Total score of 4–6.
PONV, Postoperative nausea and vomiting; POV, postoperative vomiting.
Patient-Related Factors Not Associated With Increased POV
Preoperative anxiety has not been shown to be associated with increased POV in children. Although adult smokers have lower PONV rates, the effect of secondhand smoking on POV in children is unknown.
Management
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