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PERSPECTIVE article

Front. Anesthesiol.
Sec. Perioperative Medicine
Volume 3 - 2024 | doi: 10.3389/fanes.2024.1525030
This article is part of the Research Topic Advancements and Challenges in Perioperative Medicine: 2023 View all 7 articles

Historical Perspectives Supporting the Ambitious Anesthetist Aiming for Zero Nausea/Vomiting: Should One Trust Every Consensus Statement Every Time?

Provisionally accepted
Brian A. Williams Brian A. Williams 1,2*Christopher A. Schumacher Christopher A. Schumacher 1Ridhi Choragudi Ridhi Choragudi 1Kelly E. Garbelotti Kelly E. Garbelotti 2John M. Ludden John M. Ludden 2Daniel E. Hall Daniel E. Hall 1,2
  • 1 University of Pittsburgh, Pittsburgh, United States
  • 2 VA Pittsburgh Healthcare System, Veterans Health Administration, United States Department of Veterans Affairs, Pittsburgh, Pennsylvania, United States

The final, formatted version of the article will be published soon.

    Within the domain of perioperative prophylaxis against postoperative nausea and/or vomiting (PONV), there seems to be (i) a consensus-guided "hard stop" recommendation after four prophylactic anti-emetic medications are utilized, and (ii) an assumption that each of the four "usual" PONV medications/categories produces 25% risk reduction from the "previous baseline", representing a "law of diminishing returns." Meanwhile, recentlydescribed 5-medication PONV prophylaxis (palonosetron, perphenazine, aprepitant, dexamethasone, diphenhydramine) has been observed to achieve 90-95% prophylaxis success, particularly in patients receiving intrathecal morphine (a known, potent emetogenic stimulus). This meaningful prevention thematically differs from the scholarly prevention benchmark that may be over-reliant on patient-specific preoperative risk factors, described in the 1990s and before, dictating prophylaxis strategies. Meaningful prevention with 5-medication PONV prophylaxis (which we recommend before entry into the operating theater) (i) may serve as a surprisingly effective antecedent to further avoid postoperative opioids, (ii) may be augmented throughout hospitalization and convalescence with daily "booster dosing", and (iii) may (in combination with booster dosing) mitigate possible "rebound nausea" that has been reported by esteemed PONV thought leaders in the context of post-discharge nausea and/or vomiting. The described processes (pan-prophylaxis before emetic stimuli are incurred, antiemetic booster dosing, and potential downstream opioid reduction by enhancing adherence to postoperative oral/enteral non-opioid analgesic formulations) would seem to create a win-win scenario for patients and hospitals alike. The described antiemetic techniques remain compatible with available opioid-free anesthetic techniques (lidocaine, acetaminophen, N-methyl-D-aspartate [NMDA] antagonists, etc.). Some perspectives shared herein may further inform as to how and why.

    Keywords: Palonosetron, Perphenazine, Aprepitant, Diphenhydramine, Dexamethasone, Intrathecal morphine, Postoperative Nausea and Vomiting

    Received: 08 Nov 2024; Accepted: 27 Dec 2024.

    Copyright: © 2024 Williams, Schumacher, Choragudi, Garbelotti, Ludden and Hall. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

    * Correspondence: Brian A. Williams, University of Pittsburgh, Pittsburgh, United States

    Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.