APFEL and PONV

Summary by Al-Awwab Dabaliz, 12.06.21

A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting

Authors: Christian C. Apfel, M.D., Kari Korttila, F.R.C.A., Ph.D., … for the IMPACT Investigators

June 2004; NEJM

Background: Untreated, one third will have postoperative nausea, vomiting, or both. Patients often rate postoperative nausea and vomiting as worse than postoperative pain, decreases satisfaction, delays PACU discharge and the leading cause of unexpected admissions for ambulatory patients.

Population: 28 participating centers, 5199 adults enrolled, All the patients had a risk of postoperative nausea and vomiting >40 percent, based on the presence of at least two of the following risk factors: female sex, nonsmoker status, previous history of postoperative nausea and vomiting or motion sickness, and anticipated use of postoperative opioids.

Outcome: Primary outcome measure was the incidence of any nausea, emetic episodes (retching or vomiting), or both (i.e., postoperative nausea and vomiting) during the first 24 postoperative hours.

Results: 1731 of 5161 patients (34 percent) had postoperative nausea and vomiting (59 percent among patients who were given volatile anesthesia, nitrous oxide, fentanyl, and no antiemetics and 17 percent among patients who received propofol, nitrogen, remifentanil, ondansetron, dexamethasone, and droperidol).

Summary: Increasing the number of antiemetics administered reduced the incidence of postoperative nausea and vomiting from 52 percent when no antiemetics were used to 37 percent, 28 percent, and 22 percent when one, two, and three antiemetics, respectively, were administered.

ASA Consensus Guidelines Summarized:

The general guidance:

1.       Identify at risk patients

2.       Reduce baseline risk for PONV (see table 3 below)

3.       Administer PONV prophylaxis using 2 interventions in adults at risk

4.       In children: administer PONV prophylaxis in at risk patients, combination therapy is most effective

5.       Provide Antiemetic Treatment to Patients With PONV Who Did Not Receive Prophylaxis or When Prophylaxis Failed

6.       Ensure General Multimodal PONV Prevention and Timely Rescue Treatment Is Implemented in the Clinical Setting

7.       Administer Multimodal Prophylactic Antiemetics in Enhanced Recovery Pathways