Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Anaesthesiology
journal homepage: www.elsevier.com/locate/bean

Management of postoperative nausea and

vomiting in the context of an Enhanced Recovery
after Surgery program
Jonathon Schwartz, MSE, MD, Clinical Assistant Professor,
Tong J. Gan, MD, MHS, FRCA, MBA, Professor and Chair *
Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY 11794-8480, USA

Keywords:
The concept of Enhanced Recovery after Surgery (ERAS) emerged
antiemetic
at the turn of the millennium and quickly gained footing world-
colorectal surgery
corticosteroids wide leading to the establishment of institutional ERAS protocols
dexamethasone and subspecialty guidelines. While the use of postoperative nausea
Enhanced Recovery after Surgery and vomiting (PONV) prophylaxis predates ERAS by a significant
goal-directed fluid therapy extent, the emergence of ERAS amplified the importance of anti-
guidelines emetic prophylaxis in perioperative care and drew attention to the
5-HT3 truly multifactorial nature of postoperative gastrointestinal
multimodal analgesia dysfunction. The following discussion will review key paradigms
ondansetron
behind PONV prophylaxis and ERAS, highlight the interrelation-
opioid-sparing
ship between these two endeavors, and then explore subspecialty
postoperative gastrointestinal dysfunction
postoperative nausea and vomiting ERAS guidelines that uniquely influence PONV prophylaxis.
preoperative carbohydrate loading Attention will center on the ERAS Society guidelines (ESGs) as the
preoperative fasting primary representative of current ERAS practice, though many
prophylaxis deviations from the guidelines exist within the literature and
surgery institutional practices.
ERAS paradigms © 2020 Elsevier Ltd. All rights reserved.

Enhanced Recovery after Surgery (ERAS) describes a multifaceted, structured approach to periop-
erative care that aims to expedite a patient's functional recovery by mitigating the surgical stress
response [1,2]. The first ERAS program surfaced in 2001 from European surgeons in the ERAS Study
Group with the goal to redirect attention toward quality in surgical recovery, rather than speed. By

* Corresponding author.
E-mail addresses: Jonathon.Schwartz@stonybrookmedicine.edu (J. Schwartz), Tong.Gan@stonybrookmedicine.edu (T.J. Gan).

https://doi.org/10.1016/j.bpa.2020.07.011
1521-6896/© 2020 Elsevier Ltd. All rights reserved.

Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the
context of an Enhanced Recovery after Surgery program, Best Practice & Research Clinical Anaesthesi-
ology, https://doi.org/10.1016/j.bpa.2020.07.011
2 J. Schwartz, T.J. Gan / Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx

focusing on quality over speed, ERAS distinguished itself from the fast-track surgery concept that
appeared five years beforehand [3]. The original ERAS program formulated in 2001 concentrated
specifically on colorectal surgery (CRS) patients [4]. Since that time, many ERAS programs have
emerged in many types of elective major surgery spanning across most surgical specialties [5e16]. All
of these programs focus on minimizing physiological disturbances after surgery while promoting
practices that accelerate recovery [4].
The ERAS Society guidelines (ESGs) for CRS exemplify key strategies employed by ERAS pro-
grams across surgical specialties and institutions. The essential goal within a colorectal ERAS
program is to accelerate gastrointestinal (GI) recovery by avoiding fasting, maintaining fluid bal-
ance to enhance bowel movements, avoiding opioids, utilizing epidural analgesia to blunt adverse
neuroendocrine responses, avoiding anti-inflammatory agents solely to suppress the stress
response, avoiding tubes and drains, and promoting active mobilization [8]. Supporting each pro-
gram is a list of evidence-based, best practice recommendations for each phase of perioperative
care that lead to improved outcomes, decreased length of stay (LOS), and lower costs of care when
applied consistently [3,4].
For example, one study found that the implementation of a colorectal fast-track or ERAS program
produced a 2-day reduction in LOS following sigmoid resection, while a separate meta-analysis found a
50% reduction in complications, along with subsequent studies supporting the findings [17e20].
Implementing an ERAS pathway for minimally invasive gynecologic oncology surgery was asso-
ciated with a higher likelihood of discharge on the first post-operative day, a decrease in post-
operative pain scores, a 30% reduction in opioid use, and a decrease in total hospitalization cost by 12%
without changing readmission, reoperation, or mortality rates. These findings relied on a high
adherence to multimodal postoperative nausea and vomiting (PONV) prophylaxis in the ERAS
pathway [21]. Better adherence to the elements within an ERAS protocol was associated with better
outcomes in hospitals with established enhanced recovery programs [22]. The reduction in LOS,
complications, and readmissions following ERAS implementation helped save upwards of
$2800e$5900 per patient [23].

The interaction between postoperative nausea and vomiting and Enhanced Recovery after
Surgery

The many components of care that comprise an ERAS pathway bundle indirectly help to achieve the
goal of PONV prevention primarily through the structured reduction of postoperative pain and
consequent opioid exposure [1]. The occurrence of PONV ultimately derives from the summative
emetogenic and anti-emetic effects of patient exposures throughout the perioperative experience.
Additionally, interactions between different emetogenic factors may contribute to additional increases
in PONV occurrence. Patients having zero risk factors according to the Apfel and Koivuranta risk models
may still suffer a baseline PONV incidence of 10e20% [24,25]. This baseline incidence of PONV may
reflect the contribution of latent factors for which ERAS programs may afford further efficacy to pre-
vent PONV.
For example, ERAS elements such as preoperative carbohydrate loading and limiting fasting of clear
liquids have been shown to reduce the incidence of PONV in patients undergoing abdominal surgery
[26,27]. Another example includes the avoidance of prophylactic nasogastric intubation, which may
accelerate bowel recovery and decrease PONV [15,28]. Additional means by which ERAS components
may decrease PONV indirectly are outlined in Fig. 1.
Conversely, the practice of PONV prevention and treatment remains a core component of ERAS
pathways to facilitate GI recovery, attenuate postoperative physiological stress, and improve patient
comfort to partake in rehabilitative activities such as mobilization, physical therapy, and enteral intake.
While ERAS components, namely, multimodal analgesia, may ultimately decrease the PONV risk, the
inclusion of a definitive PONV prevention and treatment component remains essential. PONV pre-
vention in ERAS patients requires identification of patients that warrants additional anti-emetic
therapy secondary to elevated baseline risk from non-modifiable risk factors.
Interestingly, PONV represents a major facet within the more general process of postoperative
gastrointestinal dysfunction (POGD). The American Society for Enhanced Recovery (ASER) and

Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the
context of an Enhanced Recovery after Surgery program, Best Practice & Research Clinical Anaesthesi-
ology, https://doi.org/10.1016/j.bpa.2020.07.011
 J. Schwartz, T.J. Gan / Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx 3

Fig. 1. ERAS components may decrease baseline PONV risk.

Perioperative Quality Initiative (POQI), in an evidence-based consensus guidelines, recommended a

strategy to quantify the extent of POGD after surgery through the development of an I-FEED scoring
system that encompasses intake, feeling nauseated, emesis, physical examination, and duration of
symptoms [29]. The concept of POGD unifies the role of ERAS interventions on PONV, which otherwise
would be construed as solely attributable to anesthesia.
Ever since the original ERAS pathways emerged in CRS, numerous surgical subspecialties adapted
ERAS pathways for specific patient populations, ultimately bringing unique considerations and con-
straints into pathway components. A summary of ERAS programs across subspecialties is displayed in
Table 1. Additional society recommendations directly connected to specific ERAS elements are listed in
Table 2. A key consideration is how subspecialty ERAS pathways may impose limits on analgesic op-
tions and thereby raise the chance of relying on opioid-based analgesia. The following sections will
highlight some important distinctions between ESGs regarding ERAS elements that could impose
challenges toward PONV management.

Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the
context of an Enhanced Recovery after Surgery program, Best Practice & Research Clinical Anaesthesi-
ology, https://doi.org/10.1016/j.bpa.2020.07.011
 Table 1

4
ology, https://doi.org/10.1016/j.bpa.2020.07.011
context of an Enhanced Recovery after Surgery program, Best Practice & Research Clinical Anaesthesi-
Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the

Subspecialty ERAS guidelines and comparison on major ERAS elements.

ERAS Society subspecialty Publication Multimodal Anesthetic Analgesic Perioperative Minimize Preoperative Stimulation of Routine
guideline year PONV protocol recommendations fluid fasting? carbohydrate bowel prophylactic
prophylaxis management loading movement nasogastric
intubation

Colorectal surgery [10,30] 2009, 2012 Y Cerebral MMSA with NSAIDs GDFT for high- Y Y May utilize N
monitoring & and APAP, weaker risk patients only alvimopan,

J. Schwartz, T.J. Gan / Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx
NMB evidence for TEA chewing gum,
bisacodyl,
MgO2,
daikenchuto
and coffee
Elective colonic surgery [31] 2012 Y Y, SAA, employ, TEA, minimize GDFT, for high- Y Y, DM patients May employ N
neuraxial opioids for risk and can receive chewing gum,
techniques breakthrough, prolonged with and in opioid-
NSAIDs and procedures. antidiabetics based analgesia
acetaminophen Vasopressors magnesium &
appropriate permissible for alvimopan
EIH.
Elective rectal/pelvic surgery [30] 2012 Y GA with MMSA, TEA for GDFT with TOD. Y Y, for non-DM Chewing gum N
neuraxial laparotomy, spinal patients and oral
technique for laparoscopy, laxatives
weak evidence for should be used
wound or TAP in a multimodal
catheters approach
Pancreaticoduodenectomy [9] 2012 Y TIVA with TEA advised. Weak Target Euvolemia, Y Y except Oral laxatives N
propofol and evidence for PCA & GDFT with TOD. diabetics and chewing
remifentanil IV lidocaine. Weak Balanced gum may be
with high PONV evidence for wound crystalloids used.
risk patients and TAP catheters. preferred to NS
Radical cystectomy for bladder 2013 Y Y, SAA, MMSA along with GDFT with TOD in Y Y, except Chewing gum N
cancer [6] neuraxial TEA high-risk patients diabetics and oral
techniques magnesium
Gastrectomy [13] 2014 Y Y MMSA, TEA, strong GDFT in high-risk Y Y, except Oral laxatives N
rec for TAP block, patients; diabetics and bowel
wound catheter, Balanced stimulants such
lidocaine infusion, crystalloids as magnesium
and PCA preferred to NS, and chewing
may use gum may be
vasopressors for considered
EIH
 Gastrointestinal surgery [32] 2015 Y Y, targeted MMSA, opioid GDFT in Y Y except Multimodal N
ology, https://doi.org/10.1016/j.bpa.2020.07.011
context of an Enhanced Recovery after Surgery program, Best Practice & Research Clinical Anaesthesi-
Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the

anesthetic sparing with RA moderateehigh- emergent prevention

depth, SAA risk patients. procedures or strategy
delayed GI
motility.
Bariatric surgery [16] 2016 Y No specific MMSA, LIA, TEA Avoid excess Y N No specific N
anesthetic fluids for comment
protocol rhabdomyolysis

J. Schwartz, T.J. Gan / Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx
endorsed prevention. Use
GDFT with SVV as
an option. D/C
postop fluid
ASAP.
Liver surgery [12] 2016 Y No specific MMSA with adjunct Target CVP  5 Y Y, except Use of N
comment wound catheter or cm H2O, Balanced diabetics stimulants to
TAP block, but crystalloid recover
recommend against preferred over NS postoperative
TEA or colloids ileus are not
indicated
Major head and neck cancer 2016 Y Y, targeted MMSA with GDFT Y Y No specific No specific
surgery with free flap anesthetic NSAIDs, COX comment comment
reconstruction [33] depth inhibitors, & APAP;
add PCA if
insufficient. No recs
on RA
Breast reconstruction [34] 2017 Y GA with TIVA MMSA, no specific GDFT. May use Y Y No specific No specific
recs for RA vasopressors to comment comment
support fluid
management
Esophagectomy [11] 2019 Y Y, BIS and LPV TEA, PVB GDFT for high- Y Y Epidural, Nasogastric
alternatively, risk patients only normovolemia, tube
MMSA with APAP, as well as decompression
using NSAIDs case laxatives and at the time of
by case, weak recs chewing gum esophageal
for gabapentin, postoperatively resection is
ketamine, and currently
lidocaine infusion recommended
with the caveat
of considering
early removal
(continued on next page)

5
 Table 1 (continued )

6
ology, https://doi.org/10.1016/j.bpa.2020.07.011
context of an Enhanced Recovery after Surgery program, Best Practice & Research Clinical Anaesthesi-
Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the

ERAS Society subspecialty Publication Multimodal Anesthetic Analgesic Perioperative Minimize Preoperative Stimulation of Routine
guideline year PONV protocol recommendations fluid fasting? carbohydrate bowel prophylactic
prophylaxis management loading movement nasogastric
intubation

Lung surgery [5] 2019 Y Y, SAA, GA with MMSA with NSAID Target euvolemia Y Y No specific No specific
LPV, include and APAP; Consider comment comment
neuraxial ketamine as

J. Schwartz, T.J. Gan / Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx
analgesia adjunct and
dexamethasone for
analgesia.
Total hip replacement and total 2019 Y No specific MMSA with APAP Target euvolemia Y N No specific N
knee replacement surgery [35] protocol recs, and NSAIDs, adding comment
GA and/or LIA for TKR but not
neuraxial THR
techniques
Cardiac surgery [7] 2013, 2019 No specific No specific Opioid-sparing GDFT Y Y No specific No specific
comment comment MMSA, no specific comment comment
recs for RA
Gynecologic/oncology [14,36,37] 2015, 2019 Y Y, SAA, MSSA with LIA at GDFT for high- Y Y Target N
monitoring incision risk patients with euvolemia, use
NMB, use LPV advanced opioid-sparing
hemodynamic analgesia
monitoring as including
needed liposomal
bupivacaine,
and alvimopan.
Permit coffee
drinking.

Acronyms in Table: APAP, Acetaminophen; BIS, Bispectral Index; COX, Cyclooxygenase; DM, Diabetes Mellitus; EIH, Epidural-Induced Hypotension; GA, General Anesthesia; GDFT, Goal-
Directed Fluid Therapy; LIA, Local Anesthetic Infiltration; LPV, Lung-Protective Ventilation; MgO2, Magnesium Oxide; MMSA, Multimodal Systemic Analgeisa; N, Not recommended; NMB,
Neuromuscular Blockade; NSAID, Nonsteroidal Anti-inflammatory Drug; PCA, Patient Controlled Analgesia; PVB, Paravertebral Block; RA, Regional Anesthesia; SAA, Short-Acting Agents;
TAP, Transversus Abdominis Plane; TEA, Thoracic Epidural Analgesia; THR, Total Hip Replacement; TIVA, Total Intravenous Anesthesia; TKR, Total Knee Replacement; TOD, Trans-
esophageal Doppler; Y, Yes, recommended.
 J. Schwartz, T.J. Gan / Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx 7

Table 2
Society guideline publications pertinent to specific ERAS elements.

Society guideline publication Publication year

Perioperative fluid management within ERAS for colorectal surgery [38] 2016
Optimal analgesia within ERAS for colorectal surgery [1] 2017
Measurement to maintain and improve quality of ERAS for elective colorectal surgery [4] 2017
Postoperative gastrointestinal dysfunction within an enhanced recovery pathway 2018
for elective colorectal surgery [29]
Perioperative opioid minimization in opioid-naive patients [39] 2019
Perioperative management of patients on preoperative opioid therapy [40] 2019

ASER: American Society for Enhanced Recovery; POQI: Perioperative Quality Initiative.

Gastrointestinal surgery

Elective colonic
ESGs for perioperative care in colonic surgery and colorectal surgery represent the landmark
subspecialty for which ERAS concepts emerged. The guidelines, broadly based on the Society for
Ambulatory Anesthesia PONV consensus, recommend a multimodal PONV prophylaxis regimen in
patients with 2 risk factors [41]. If PONV does occur, treatment with an agent possessing a different
mechanistic pathway should be pursued [8,10]. These ESGs explicitly recognize the indirect role of
concerted ERAS interventions in PONV occurrence, as outlined in Fig. 1.
The ESGs recommend a multimodal analgesic strategy to limit opioids with acetaminophen serving
as a central ingredient in the strategy. While concern has emerged on the risk of NSAID use and
anastomotic dehiscence, the society guidelines note insufficient evidence to recommend against NSAID
use in colonic surgery [8,10,42]. Regarding regional anesthesia, the guidelines recommend a low-dose
local anesthetic thoracic epidural analgesia (TEA) along with opioids for laparotomy, but with lapa-
roscopic surgery, a spinal with a low-dose long-acting opioid such as 0.3 mg morphine should be used
[8,10,43].
The ESGs for colonic surgery recommend the use of cardiac output (CO) measurement with LiDCO
or transesophageal Doppler (TOD) in open surgery as part of goal-directed fluid therapy (GDFT) that
may decrease PONV incidence [8,44].
The ESGs provide a strong recommendation for the use of chewing gum and alvimopan for the
prevention of postoperative ileus [8,10]. Notably, chewing gum and magnesium oxide were not
associated with a significant effect on reducing nausea [45,46]. Alvimopan is a mu-opioid receptor
antagonist that may accelerate GI recovery, including reductions in nausea and vomiting, for patients
receiving postoperative opioid analgesia [47].
The society guidelines note that minimal preoperative fasting in conjunction with carbohydrate
loading and adequate hydration may have non-pharmacological protective effects against PONV in CRS
with minimal associated risks on the basis of studies primarily in cholecystectomy patients
[8,10,26,27,48]. One Cochrane review found that preoperative carbohydrate loading decreased post-
operative time to flatus, but with limited studies available, it could not find an impact on PONV
compared to placebo or traditional fasting [49].

Rectal and pelvic surgery

The ESGs recommend TEA use after open rectal surgery, echoing the CRS recommendations [15].
The ESGs also note limited evidence for efficacy using preperitoneal wound catheters and continuous
transversus abdominis plane (TAP) blocks during rectal surgery [15,50]. No significant PONV reduction
was found with TAP blocks, and only a trend toward PONV reduction was seen with preperitoneal
ropivacaine infusions [50,51]. Adding multimodal analgesia with acetaminophen and NSAIDs can
reduce the incidence of opioid use by roughly 30% [52]. With limited evidence for ketamine, gaba-
pentin, or tramadol use on rectal surgery outcomes, the guidelines do not offer a specific recom-
mendation for or against the use of these adjuncts.

Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the
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8 J. Schwartz, T.J. Gan / Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx

The ESGs recommend preoperative oral carbohydrate loading in all non-diabetic patients, echoing
the recommendations for colonic surgery, on the basis of a study in rectal and pelvic surgery that
demonstrated a reduction in PONV, pain, diarrhea, and dizziness with the ingestion of preoperative
carbohydrate solutions [15,53]. Routine NGT placement is not advised based on a Cochrane meta-
analysis reporting earlier return of bowel function and reduced pneumonia incidence by with-
holding routine NGT placement [15,28].

Liver surgery
The ESGs for liver surgery echo recommendations for a multimodal approach to PONV prophylaxis
but highlight the potential benefit of dexamethasone in liver surgery [12]. Beyond an antiemetic effect,
low-dose dexamethasone may improve liver regeneration, though theoretical concerns about
impairing regeneration remain [54]. Regarding regional anesthesia, the ESGs advise against routine
TEA over concerns for postoperative coagulopathies postponing catheter removal, and for acute renal
failure secondary to epidural-induced hypotension (EIH) [12,55,56]. Intrathecal (IT) opioid and local
anesthetic wound infusion catheters may serve as alternatives in a multimodal regimen [57,58].
Within the context of ERAS programs for liver surgery, PONV prophylaxis should anticipate expo-
sure to perioperative opioids given concerns over neuraxial analgesia use, and likely concerns with
acetaminophen and NSAIDs. GDFT may be useful in the early period (first 6 h) after hepatic resection,
but until completion of the hepatectomy a low CVP (<5 cm H2O) is advised to prevent bleeding [12,59].

Pancreaticoduodenectomy
The ESGs for pancreaticoduodenectomy (PD) echo the recommendations for CRS, though recom-
mend the use of total intravenous anesthesia (TIVA) with propofol and remifentanil in high-risk pa-
tients rather than volatile anesthetics [60].
Unlike the CRS ESGs, the guidelines for PD highlight controversial evidence regarding the impact
that corticosteroids may have on anastomotic healing and leak, but do not explicitly recommend for or
against the use of corticosteroids [60e62]. It is the authors' opinion that the risk is low with one single
dose of steroid for the prophylaxis of PONV.

Bariatric surgery
The use of glucocorticoids (specifically 8 mg dexamethasone) in the ESGs is recommended as an
independent intervention to mitigate the perioperative stress response and secondarily prevent PONV
[16]. The use of TIVA is also suggested for reducing PONV [16]. A randomized controlled trial (RCT)
investigating opioid-free TIVA versus general inhalational anesthesia with opioids in elective bariatric
surgery found significantly less PONV (ARR 17.3%; NNT 6) in the opioid-free TIVA group. The TIVA group
utilized dexmedetomidine and propofol infusions with preemptive ketamine analgesia (0.5 mg/kg IV)
[63].
Regarding analgesia, a multimodal approach for Roux-en-Y gastric bypass using scheduled acet-
aminophen and ketorolac to replace a hydromorphone patient-controlled analgesia (PCA) decreased
opioid use by roughly 75% over the first 24 h with an associated decrease in total rescue antiemetic use
[64].

Gastrectomy
High-risk gastrectomy patients having at least three PONV risk factors should receive TIVA with
propofol and remifentanil, along with dexamethasone 4e8 mg and a 5-HT3 antagonist or droperidol
[13]. Regarding analgesia, wound infusion catheters and TAP blocks failed to show a PONV reduction
despite reaffirmation of opioid sparing in meta-analyses [65e67]. Lidocaine infusions are endorsed
after a systematic review showing decreased opioid use and PONV [68].

Urologic surgery

Current ESGs in urologic surgery focus on perioperative care following radical cystectomy for
bladder cancer [6]. TEA is advised within a multimodal regimen though one study interestingly found
no impact with TEA on PONV despite significant reductions in volitional pain and a trend toward earlier

Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the
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 J. Schwartz, T.J. Gan / Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx 9

solid food intake compared to IV PCA [69]. Endorsed alternatives to TEA, especially with minimally
invasive techniques, include lidocaine infusions, TAP blocks, and peritoneal wound infusion catheters.
Regarding bowel function recovery, the ESGs note that laparoscopy-assisted surgical technique
along with chewing gum use and alvimopan may help prevent ileus after cystectomy [70e72]. Another
RCT found that stenting the uretero-ileal anastomosis of ileal orthotopic bladder substitutes or con-
duits accelerated bowel recovery and prevented PONV [73].

Cardiothoracic surgery

These ESGs do recognize the key role opioids play in PONV along with the growing role for
multimodal, opioid-sparing analgesia [7]. Cardiac surgery poses constraints on opioid sparing strate-
gies compared to other types of surgery. In particular, postoperative NSAID analgesia use can increase
renal injury risk in an already highly vulnerable surgical group [74]. Cyclooxygenase-2 (COX-2) in-
hibitors pose a significant risk for thrombotic events after cardiac surgery [75]. Preemptive analgesia
with a single 600 mg gabapentin dose in cardiac surgery showed a significant decrease in pain and
nausea, at the expense of increased sedation adding an extra hour to mechanical ventilation [76].

Head and neck surgery

The ESGs for major head and neck surgery recommend a corticosteroid with another antiemetic as
first-line prophylaxis [33]. Vomiting is a serious complication after free-flap reconstructions of the
head and neck as it may cause suture dehiscence, wound infections, fistula formation, and flap
compromise [33,77].
The analgesic strategy recommended for head and neck surgery deviates from the other ESGs with
the inclusion of “strong opioids” like a morphine PCA [33]. The inclusion of strong opioids stems from a
study showing no impact on PONV with PCA compared to using rescue opioid analgesics after skull
base surgery [33,78].
Beyond opioids, the guidelines advocate for individualized celecoxib use citing mixed evidence
toward flap survivability and bleeding risk [79,80]. A more recent meta-analysis, however, found no
increased risk of perioperative bleeding or blood loss with selective COX-2 inhibitors [81]. Pregabalin
and dexmedetomidine have demonstrated effective analgesia in an ERAS program for tongue recon-
struction [82,83]. Bilateral superficial cervical blocks in thyroidectomy or parathyroidectomy proced-
ures may also afford analgesia without a significant reduction in PONV [84,85].

Total hip replacement and total knee replacement

Regarding analgesic strategies for total hip (THR) and total knee replacements (TKR), the ESGs
endorse NSAIDs as part of a multimodal regimen where no contraindications exist, and concerns over
early prosthetic loosening with NSAID use are inadequately substantiated at this time [86]. Questions
over analgesic efficacy prevented the ESG's recommendation for routine gabapentin use despite evi-
dence for opioid sparing and PONV reduction [87,88]. The ESGs note an established role in TKR and THR
for preoperative methylprednisolone (125 mg) to improve analgesia and prevent PONV [89].
The ESGs recommend local infiltration analgesia (LIA) with TKR, which shows comparable analgesic
efficacy to a femoral nerve block, but spares the motor strength [90]. LIA is not recommended in THR,
nor is the use of infusion catheters for either THR or TKR, based on a study failing to show benefit
against multimodal, opioid-sparing systemic analgesia [91]. A large study favoring neuraxial tech-
niques over GA for THR and TKR helped initially to spur incorporation of neuraxial techniques into
most ERAS protocols [92]. More recent RCTs, however, found that neuraxial techniques may actually
prolong LOS in THR or TKR compared to propofol and remifentanil TIVA [93]. Routine neuraxial
techniques are consequently no longer recommended. The ESGs also advise against routine IT opioid
based on evidence for increased adverse respiratory events, urinary retention, and potentially PONV
[94].

Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the
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10 J. Schwartz, T.J. Gan / Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx

The ESGs for THR and TKR deviate from other subspecialties by not advising strict implementation
of carbohydrate loading on the basis of studies showing minimal reductions on an already short LOS
[49,95].

Breast surgery

The ESGs focus on 5-HT3 antagonists and the use of TIVA for GA for PONV prevention. NSAIDs are
endorsed as part of multimodal analgesia without any significant bleeding risk [34]. Regarding regional
anesthesia, one study found that the addition of a TAP block did not reduce the incidence of PONV in
this population compared to GA alone [96]. But despite the reported inefficacy of TAP blocks within the
guidelines, one randomized trial found a significant reduction in fentanyl consumption intra-
operatively and lower PONV in the PACU when a PECS II block was added to the general anesthetic for
breast cancer surgery [97].

Gynecologic surgery

Given that laparoscopic procedures, gynecologic surgery, and N2O are independent predictors for
PONV, the ESGs explicitly recommend omission of N2O [14,98]. Incisional injection of bupivacaine
(including liposomal preparations) can be employed instead of TAP blocks or epidurals alongside
multimodal systemic analgesia [14,99]. Preemptive analgesia with gabapentinoids has been shown to
reduce PONV in gynecologic surgery [100].
Additional recommendations that indirectly influence PONV include the recommendation for
minimally invasive surgical techniques and prevention of ileus with coffee intake and alvimopan
[14,72,101,102].

Summary

The emergence of ERAS has created a new context for PONV prophylaxis by drawing attention to the
truly multifactorial nature of PONV and POGD more broadly. The many components of care that
comprise an ERAS pathway bundle indirectly help to achieve the goal of PONV prevention primarily
through the structured reduction of postoperative pain and consequent opioid exposure via multi-
modal analgesia. Conversely, PONV prophylaxis through anesthetic planning and antiemetic admin-
istration helps assist the return of bowel function that ERAS programs aim toward. The emergence of
surgery-specific ERAS pathways has brought unique considerations and constraints into pathway
components, particularly by recommending against certain analgesics or nerve blocks, which may
counteract opioid-sparing techniques to limit PONV. Despite the many similarities between subspe-
cialty ESGs, the small distinctions between these pathways highlight opportunities for further research
to answer questions on the efficacy of interventions such as chewing gum on POGD or the risks of
NSAIDs on wound dehiscence.

Practice points

- Postoperative nausea and vomiting (PONV) prophylaxis within an Enhanced Recovery after
Surgery (ERAS) setting should employ a standardized, risk-based prophylaxis strategy with
multimodal antiemetic therapy for prevention and treatment.
- ERAS protocols seek to expedite high-quality patient recovery through a structured, periop-
erative arrangement of evidence-based interventions including PONV prophylaxis and
opioid-sparing analgesia.
- Many interventions within an ERAS program indirectly facilitate PONV prevention through
limiting precipitating factors like opioid exposure, volatile anesthetic use, routine nasogastric
intubation, and prolonged preoperative fasting of clear liquids.

Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the
context of an Enhanced Recovery after Surgery program, Best Practice & Research Clinical Anaesthesi-
ology, https://doi.org/10.1016/j.bpa.2020.07.011
 J. Schwartz, T.J. Gan / Best Practice & Research Clinical Anaesthesiology xxx (xxxx) xxx 11

Research agenda

- Studies are needed to corroborate the direct anti-emetic potential of minimal preoperative
fasting, preoperative carbohydrate loading, and agents such as caffeine or chewing gum.
- Studies are needed to examine the significance of routine corticosteroid and NSAID use
within Enhanced Recovery after Surgery programs on the risk for wound dehiscence and
bleeding.

Conflict of interest/Funding

None.

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Please cite this article as: Schwartz J, Gan TJ, Management of postoperative nausea and vomiting in the
context of an Enhanced Recovery after Surgery program, Best Practice & Research Clinical Anaesthesi-
ology, https://doi.org/10.1016/j.bpa.2020.07.011