Synopsis
Prevent and treat postoperative nausea and vomiting in adults through structured risk assessment, baseline-risk reduction, multimodal prophylaxis and mechanism-aware rescue treatment.
- Estimate adult PONV risk from prior PONV or motion sickness, female sex, non-smoking status and expected postoperative opioid use, then account for procedure and anaesthetic factors.
- Reduce baseline risk with opioid-sparing multimodal analgesia, hydration, regional techniques where suitable and propofol total intravenous anaesthesia when clinically appropriate.
- Current fifth consensus guidance supports at least two prophylactic interventions for adults at any risk, selected for different mechanisms, timing, contraindications and duration.
Key red flags
Reduced consciousness with active vomiting creates an immediate aspiration risk and requires airway positioning, suction and senior airway help.
Vomiting with abdominal distension, peritonism, absent output or severe escalating pain may indicate ileus, obstruction, leak or another surgical complication.
Haematemesis, shock, new hypoxaemia, chest pain or neurological deterioration needs urgent cause-directed assessment rather than serial antiemetics.
Breakthrough PONV after prophylaxis should be treated with a different agent or pharmacological class; immediate redosing of the failed class adds little benefit.
QT prolongation, Parkinsonism, extrapyramidal risk, glaucoma, pregnancy, diabetes and drug interactions alter antiemetic selection.
Adult risk models and prophylactic regimens should not be applied directly to children; paediatric postoperative vomiting has separate prediction and treatment guidance.
Vomiting with reduced airway reflexes, weak cough or hypoxaemia requires immediate airway positioning, suction and escalation.
Distension, peritonism, escalating pain, haemodynamic change or absent gastrointestinal recovery suggests more than uncomplicated PONV.
Reasoning priorities
Identify susceptibility and select preventive intensity before anaesthesia.
Use the score to support a protocol while considering operation and anaesthetic exposure; it is less reliable if adult predictors are applied to children.
Worked reasoning
A non-smoking adult woman with previous motion sickness expects postoperative opioid treatment after laparoscopic surgery.
- Record the adult risk factors and review procedure, anaesthetic, comorbidity and medicine contraindications before selecting prophylaxis.
- Reduce baseline risk with opioid-sparing multimodal analgesia, adequate hydration and a propofol-based technique where appropriate for the whole anaesthetic plan.
- Give at least two appropriately timed prophylactic interventions with different mechanisms under the local formulary, checking glucose, QT and other patient-specific cautions.
- At handover state exactly what was given and when so that recovery staff can choose an effective different-class rescue if symptoms break through.