An update on the management of PONV in a pediatric patient.
This article provides a detailed review of postoperative nausea and vomiting (PONV) in the paediatric population, focusing on risk stratification, prophylactic therapies and strategies for management of PONV. The aim was to serve as an update of changes in these areas over the last decade.
Given the high incidence of PONV in children, single agent prophylaxis for all is not an unreasonable approach, reserving multi-modal prophylaxis for those at moderate to high risk. Use of risk stratification systems can aid targeting those most at risk, however, these scoring systems remain fairly basic and do not account for inter-individual variation. Furthermore, the challenge of diagnosing nausea in the paediatric patient may also be aided by scoring systems, such as the aptly named BARF (Baxter Retching Faces) scale.
The pharmacological armamentarium against PONV is set to grow into the future as we look to chemotherapy induced nausea and vomiting (CINV) therapies that have been shown to be safe in children, namely neurokinin-1 receptor antagonists. There is also growing interest in the use of olanzapine (an atypical antipsychotic agent with dopamine antagonist activity) in CINV, with limited data in the postoperative setting. Newer, longer-acting 5-HT3 antagonists are yet to be approved for use in children, however may be preferable as post-discharge nausea and vomiting becomes increasingly recognized.
The use of preoperative carbohydrate oral solution may also become more prominent as reduction in PONV as well as other potential benefits are demonstrated. In addition, early adult data suggests sugammadex is associated with less PONV when compared to neostigmine for reversal of neuromuscular blockade.
For now, 5-HT3 antagonists remain the cornerstone of management of PONV, as well as risk modification techniques including minimisation of opioids, use of intraoperative intravenous fluids and total intravenous anaesthesia.
Reviewed by Dr. Natalie Akl