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anesthesia.ponv-postop-nausea-vomiting.core.v1

Postoperative Nausea and Vomiting

general_internal_medicineacuteadultpediatricacuteinpatientoutpatient
Start encounter →Print handoutPRODUCTION

Lane-C anesthesia campaign — PONV per SAMBA 2020 with Apfel 1999 risk score driving multimodal prophylaxis. All RxCUIs RxNav-verified live 2026-05-26: ondansetron 26225, dexamethasone 3264, aprepitant 358255, droperidol 3648 (black-box QT), scopolamine 9601, metoclopramide 6915 (limited evidence — reserve for gastroparesis overlap), haloperidol 5093, promethazine 8745. PMIDs 32467512 (Gan SAMBA 2020) and 10485781 (Apfel 1999) live-verified via PubMed MCP. Rescue rule: do not repeat same class within 6h.

Entry points (4)

  • symptom
    Postoperative nausea (within 24h of anesthesia) (SAMBA 2020)
    postop_nausea
  • symptom
    Postoperative vomiting or retching (within 24h of anesthesia) (SAMBA 2020)
    postop_vomiting_retching
  • history
    Apfel score >=2 (female + nonsmoker + prior PONV/motion sickness + postop opioids) (Apfel 1999)
    apfel_score_high_risk
  • history
    Laparoscopic, gynecologic, ENT, breast, ophthalmologic, or strabismus surgery (SAMBA 2020)
    laparoscopic_or_high_emetogenic_surgery

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Children >=3 yrs receive different prophylaxis dosing; pediatric POV scoring uses Eberhart score, not Apfel (SAMBA 2020)
  • sexrequired
    demographic • used at RISK_STRATIFICATION
    Female sex = 1 Apfel point (Apfel 1999)
  • smoking_statusrequired
    history • used at RISK_STRATIFICATION
    Non-smoker = 1 Apfel point (Apfel 1999)
  • prior_ponv_motion_sicknessrequired
    history • used at RISK_STRATIFICATION
    Prior PONV or motion sickness = 1 Apfel point (Apfel 1999)
  • planned_postop_opioidsrequired
    history • used at RISK_STRATIFICATION
    Postoperative opioids = 1 Apfel point (Apfel 1999)
  • surgery_typerequired
    history • used at CONTEXT
    Laparoscopic, gynecologic, ENT, breast, ophtho/strabismus = high-emetogenic (SAMBA 2020)
  • qt_prolonging_meds_or_baseline_qtrequired
    history • used at CONTEXT
    Droperidol black-box; ondansetron QT effect cumulative; baseline QT informs choice (SAMBA 2020)
  • parkinsons_or_dopamine_sensitivity
    history • used at CONTEXT
    Avoid dopamine antagonists (metoclopramide, droperidol, haloperidol, promethazine) in Parkinsons (SAMBA 2020)
  • rescue_nausea_severity
    symptom • used at TREATMENT
    Rescue threshold = patient distress; rescue with class different from prophylaxis (SAMBA 2020)

12-phase flow (12)

  1. 1FRAME
    Confirm PONV scope — risk-stratify pre-induction, deliver multimodal prophylaxis matched to Apfel/Eberhart score, rescue with different drug class if breakthrough (SAMBA 2020)
    inputs: age
    advance: risk assessment initiated
  2. 2ENTRY
    Preoperative anesthesia evaluation OR PACU nausea/vomiting symptom (SAMBA 2020)
    advance: triggered
  3. 3CONTEXT
    Surgery type (emetogenicity), opioid plan, anesthetic plan (volatile vs TIVA), prior PONV, motion sickness, baseline QT, dopamine sensitivity (SAMBA 2020)
    inputs: surgery_type, planned_postop_opioids, qt_prolonging_meds_or_baseline_qt, parkinsons_or_dopamine_sensitivity
    advance: context complete
  4. 4RED_FLAGS
    Aspiration, refractory vomiting with electrolyte abnormality, suspected bowel obstruction, neurologic cause for vomiting — escalate beyond standard antiemetics (SAMBA 2020)
    advance: red flags identified or excluded
  5. 5INITIAL_WORKUP
    Apfel score (4 factors); Eberhart POV score in pediatrics; ECG QT if multiple QT-active antiemetics planned (SAMBA 2020, Apfel 1999)
    inputs: sex, smoking_status, prior_ponv_motion_sickness, planned_postop_opioids
    advance: risk score assigned
  6. 6BRANCHING_WORKUP
    BMP if refractory vomiting + dehydration / hypokalemia; abdominal exam + imaging if surgical complication suspected (SAMBA 2020)
    advance: workup as indicated
  7. 7DIFFERENTIAL
    Distinguish PONV from postop ileus, opioid effect, bowel obstruction, electrolyte derangement, raised ICP, vestibular cause (SAMBA 2020)
    advance: cause clarified
  8. 8RISK_STRATIFICATION
    Apfel: 0-1 low (~10-20%); 2 medium (~40%); 3-4 high (~60-80%). Eberhart pediatric: age >=3, strabismus, vomiting hx, family hx PONV. Match number of antiemetic classes to score (SAMBA 2020, Apfel 1999)
    inputs: sex, smoking_status, prior_ponv_motion_sickness, planned_postop_opioids
    advance: risk tier + prophylaxis plan locked
  9. 9TREATMENT
    Multimodal prophylaxis: ondansetron 4 mg IV near end of case + dexamethasone 4-8 mg IV at induction; add aprepitant 40 mg PO preop for high-risk laparoscopic; consider TIVA + opioid-sparing analgesia + carb/IV fluids; rescue with different class (e.g. droperidol 0.625 mg IV with QT caution, haloperidol 1 mg IV low-dose, promethazine, scopolamine patch the night before) (SAMBA 2020)
    inputs: rescue_nausea_severity, qt_prolonging_meds_or_baseline_qt
    advance: multimodal plan delivered
  10. 10DISPOSITION
    PACU discharge when controlled and tolerating PO; admit if refractory or surgical complication (SAMBA 2020)
    advance: disposition determined
  11. 11MONITORING
    Nausea VAS, vomiting episodes, hydration, electrolytes if refractory; QT if multiple QT-active antiemetics; aspiration screen (SAMBA 2020)
    advance: symptoms controlled
  12. 12FOLLOWUP
    Document PONV event in chart for future anesthetics; counsel re prior-PONV factor and aprepitant prophylaxis for future high-risk surgery (SAMBA 2020)
    advance: documentation + counseling complete