Postoperative nausea and vomiting
Nausea and vomiting within 24 hours of surgery. Risk factors: female sex, non-smokers, history of PONV or motion sickness, perioperative use of volatile anesthetics and opioids. Risk-stratified prophylaxis (Apfel score) uses 5-HT3 antagonists (ondansetron), dexamethasone, droperidol, and metoclopramide.
ICD-10 R116 drugs
Also known as: PONV
Drugs used for this condition
- AAmisulprideSecond line · Atypical antipsychotic of the benzamide classLow-dose intravenous amisulpride (5–10 mg) is used to prevent and treat postoperative nausea and vomiting. Several double-blind, placebo-controlled RCTs, a meta-analysis and the Fourth Consensus Guidelines on postoperative nausea and vomiting include amisulpride as one of the recommended antiemetics. The antiemetic dose (5–10 mg IV) is far below the antipsychotic dose (400–800 mg orally) and does not meaningfully prolong the QT interval. In Spain the intravenous form (Barhemsys) is not registered and CIMA lists only oral tablets; the basis is FDA approval (2020) and international consensus.
- AGranisetronFirst line · 5HT3 serotonin receptor antagonistFirst-line option for postoperative nausea and vomiting prophylaxis and treatment, alongside ondansetron.
- AOndansetronFirst line · 5-HT3 serotonin receptor antagonistPrevention and treatment of postoperative nausea and vomiting in high-risk patients (female sex, non-smoker, history of PONV or motion sickness). Standard dose 4 mg IV 30 minutes before surgery ends. In patients at risk of recurrence, repeat the dose or combine with dexamethasone and/or droperidol.
- BDomperidoneSecond line · Prokinetic, peripheral dopamine D2 receptor antagonistSecond-line for nausea and vomiting per EMA 2014 after restriction. Dose 10 mg up to 3 times daily for max 1 week. First-line: 5-HT3 antagonists (ondansetron), with dexamethasone or metoclopramide as needed. Before start and with concomitant QT-prolonging drugs, assess cardiovascular risk.
- BDroperidolSecond line · First-generation antipsychotic, butyrophenone. Used as antiemetic.Droperidol is second-line antiemetic for postoperative nausea and vomiting when ondansetron and metoclopramide fail. EMA recommends 0.625–1.25 mg IV. Use requires ECG screening due to boxed warning for torsades de pointes.
- BMetoclopramideSecond line · Prokinetic, dopamine D2 receptor antagonistSecond-line option for postoperative nausea and vomiting prophylaxis and treatment after ondansetron. The 2014 AEMPS alert caps courses at 5 days and the adult dose at 30 mg/day because of extrapyramidal risk.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit