Postoperative nausea causes significant discomfort in surgical patients, and while it is not directly implicated in an increased mortality, it is associated with increased risk of pulmonary embolism, longer hospital stays and complications to rehabilitation³. It is thus an important postoperative sequela to avoid³. Prior studies have shown that opioid administration during certain procedures may increase the incidence of postoperative nausea and vomiting (PONV)³.

One such example is total arthroplasty, which is a category of extensive and very painful procedures that require intraoperative pain management³. A study from 2017 showed that epidural administration of fentanyl during total knee arthroplasty increased the incidence of PONV across the board³. A 2018 study looked at epidural administration of opioids during total hip arthroplasty and similarly found a significant association between opioid administration and PONV³. Unfortunately, both procedures are invasive and extremely painful, and reducing the quality of intraoperative pain management is not an option⁴. Thus, one study examined the risk factors that pre-disposed patients to postoperative nausea in order to help clinicians minimize its occurrence despite the use of opioid analgesics in surgery⁴. These risk factors include a history of motion sickness, smoking, female gender, perioperative anemia, and low BMI⁴. With this information, clinicians treating patients with these risk factor profiles can more actively prevent PONV⁴.

In terms of pharmacological options, dexamethasone is the mainstay prophylaxis for patients undergoing surgery with general anesthesia, and it is an effective prevention technique¹. However long-term neuraxial opioids are associated with as much as a 50% incidence of PONV and create an especially challenging problem for clinicians. A 2017 metanalysis found that IV dexamethasone can be used as effective prophylaxis in patients on long-term neuraxial opioids¹. Until this study, there was conflicting evidence about the efficacy of IV dexamethasone in preventing PONV in patients receiving neuraxial opioids¹. This meta-analysis found that, regardless of whether dexamethasone was administered early in the surgery or later, it significantly decreased likelihood of PONV in the first 24 hours after surgery¹.

While dexamethasone is an effective prophylaxis, some patients may prefer or request non-pharmacological interventions². A meta-analysis in Anesthesia and Analgesia looked at whether non-pharmacological prophylaxis approaches were effective when compared to placebo². Such interventions included acupuncture, electroacupuncture, transcutaneous electrical nerve stimulation, acupoint stimulation, and acupressure, and they were found to improve incidence of PONV in adult patients up to six hours postoperatively².

Postoperative nausea and vomiting are not directly life-threatening complications, but they cause significant discomfort to patients and do increase the duration of hospital stays. Opioid administration has been shown to increase the incidence of PONV, but in procedures that require opioids for pain management, prophylactic techniques should be considered, especially with patients at high risk for experiencing postoperative nausea and vomiting.

References

1. Grape S, Usmanova I, Kirkham KR, Albrecht E. Intravenous dexamethasone for prophylaxis of postoperative nausea and vomiting after administration of long-acting neuraxial opioids: a systematic review and metanalysis. Anaesthesia, 2017; 37(4): 480-489. doi:
2. Lee A and Done ML. The Use of Nonpharmacological Techniques to Prevent Postoperative Nausea and Vomiting. Anesthesia and Analgesia, 1999; 88(6): 1362-1369. doi: 10.1213/00000539-199906000-00031
3. Ukai T, Ebihara G, Watanabe M. Opioid administration via epidural catheter is a risk factor for postoperative nausea and vomiting in total hip arthroplasty: A retrospective study. Journal of Orthopaedic Science, 2018; 23(6): 973-976. doi: 10.1016/j.jos.2018.06.11
4. Wang Y et al. Risk factors of postoperative nausea and vomiting after total hip arthroplasty or total knee arthroplasty: a retrospective study. Annals of Transitional Medicine, 2020; 8(17): 1088. doi: 10.21037/atm-20-5486

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