Management of Postoperative Nausea and Vomiting in Children

Abstract

Postoperative nausea and vomiting (PONV) continues to be a frequent and important cause of morbidity in children. Postoperative vomiting (POV) is more commonly studied in children than postoperative nausea because of a child's inability to effectively express distress after experiencing nausea. POV is problematic in children and is one of the leading postoperative complaints from parents and the leading cause of readmission to the hospital. POV occurs twice as frequently in children as in adults, increasing until puberty and then decreasing to adult incidence rates. Gender differences are not seen before puberty. POV remains a main cause of morbidity in children because severe vomiting can be associated with dehydration, postoperative bleeding, pulmonary aspiration, and wound dehiscence. While children have an increased potential for dehydration and the resulting physiologic impairments, other associated results such as a delay in hospital discharge or an overnight or longer hospital admission also must be considered. The two most common emetogenic surgical procedures evaluated in children are strabismus repair and adenotonsillectomy. The approach to the management of PONV and POV in children is similar to that in adults. However, as the rate of POV is more frequent in children than in adults, more children are candidates for antiemetic prophylaxis. The management approach is multifactorial and involves proper preoperative preparation, risk stratification, rational selection of antiemetic prophylaxis, choice of anesthesia technique, and a plan for postoperative antiemetic therapy. It is important to identify children at moderate-to-high risk for POV as prophylactic antiemetic therapy is useful in these children. Antiemetics of choice for POV in children include dexamethasone, dimenhydrinate, perphenazine, ondansetron, dolasetron, granisetron, and tropisetron. The serotonin (5-hydroxytryptamine; 5-HT(3)) antagonists are the antiemetic drugs of first choice for POV prophylaxis in children because as a group they have greater efficacy for preventing vomiting than nausea. The 5-HT(3) antagonists can be effectively combined with dexamethasone with an increase in efficacy. If possible, regional anesthesia should be considered. For those undergoing general anesthesia, the baseline POV risk should be reduced. Children at moderate-to-high PONV risk should receive combination therapy with two or three prophylactic antiemetics from different antiemetic drug classes. Reference to and the use of PONV guidelines and management algorithms help improve cost-effective postoperative care.

Anesthetic management for pediatric strabismus surgery: Continuing Professional Development

“…The incidence of PONV without prophylaxis varies from 37-90%, 2,26,27 and untreated PONV can result in complications, such as dehydration, electrolyte imbalance, 7 subconjunctival hemorrhage, loosening of surgical attachments, delayed discharge, and unplanned admissions. 2 In addition, it may decrease satisfaction and increase the use of resources.…”

“…2 In addition, it may decrease satisfaction and increase the use of resources. 26,28 Major risk factors for postoperative vomiting (POV) in pediatric surgery include the type of surgery (e.g., strabismus surgery, tonsillectomy), age [ three years, duration of anesthesia [ 30 min, and a personal or family history of POV, PONV, or motion sickness. 7,26 In addition, there are risk factors specific to strabismus surgery that increase the incidence of POV.…”

“…26,28 Major risk factors for postoperative vomiting (POV) in pediatric surgery include the type of surgery (e.g., strabismus surgery, tonsillectomy), age [ three years, duration of anesthesia [ 30 min, and a personal or family history of POV, PONV, or motion sickness. 7,26 In addition, there are risk factors specific to strabismus surgery that increase the incidence of POV. These include the oculoemetic reflex-a centrally mediated reflex related to eye muscle manipulation, 7,27 an alteration in visual perception postoperatively, 7 a positive OCR, 7 the surgical technique, 29 and the number of repaired eye muscles.…”

“…These include the oculoemetic reflex-a centrally mediated reflex related to eye muscle manipulation, 7,27 an alteration in visual perception postoperatively, 7 a positive OCR, 7 the surgical technique, 29 and the number of repaired eye muscles. 26,30 The surgical technique, myopexy, 29 where posterior fixation of the muscle via a suture results in a more sustained stimulation, is associated with an increased incidence of POV.…”

“…26 Also, it is difficult to compare studies as there are many different anesthetic techniques, medications, and end points chosen. The majority of the literature focuses on anti-emetic prophylaxis rather than treatment in pediatric strabismus patients.…”