Authors: Gan T J et al.
Source: Anesthesia & Analgesia. November 14, 2025. DOI: 10.1213/ANE.0000000000007816
Summary:
This executive summary presents the Fifth Consensus Guidelines for postoperative nausea and vomiting (PONV), produced by an international, multidisciplinary panel to update evidence-based prevention and treatment strategies across adult and pediatric populations. The guideline emphasizes that optimal PONV care is not just a drug choice problem—it requires reliable risk identification, baseline risk reduction, multimodal prophylaxis, and a disciplined rescue strategy supported by institutional infrastructure and pathway adherence.
The panel reaffirms risk stratification using validated tools, particularly the Apfel simplified risk score for adults, while acknowledging a growing trend toward more liberal, multimodal prophylaxis because of (1) imperfect risk capture, (2) inconsistent adherence to risk-based algorithms, and (3) the generally favorable safety profile of antiemetics at standard perioperative doses. Newer literature is summarized on potential additional risk modifiers (eg, hemodynamic factors like hypotension, markers of inflammation, certain lab associations, BMI relationships, and procedure-specific risks), but the guideline stresses that adding more factors rarely improves population-level prediction—rather, these may matter most when vomiting would be especially harmful or when consequences are high.
A major focus is baseline risk reduction: using strategies that reduce emetogenic exposures and opioid burden. Key recommendations include propofol-based TIVA (or propofol supplementation), opioid-sparing multimodal analgesia (acetaminophen, NSAIDs/COX-2 inhibitors, ketamine, esmolol; selective use of lidocaine infusion depending on procedure), and regional/neuraxial techniques when appropriate. Avoidance of nitrous oxide, optimized fluid therapy, and goal-directed hemodynamics are discussed as additional tools. The guideline also addresses postdischarge nausea and vomiting (PDNV) as a distinct problem—patients lose access to rapid IV rescue—and encourages identifying high-risk patients and using longer-acting approaches prior to discharge.
For adult prophylaxis, the guideline endorses a general multimodal approach: for most adults with any meaningful PONV risk, use at least two prophylactic interventions, selecting from different pharmacologic classes and pairing drugs intelligently (commonly a 5-HT3 antagonist plus dexamethasone, with NK-1 antagonists, dopamine antagonists, scopolamine, and others as appropriate based on risk, procedure, and contraindications). The document summarizes comparative efficacy, dosing/timing considerations, and safety issues (including QT considerations and the practical implications of long-acting agents such as palonosetron or aprepitant). For rescue treatment, the key principle is to treat with an antiemetic from a different class than what was used for prophylaxis, while recognizing that evidence for “best” rescue regimens remains limited.
For children, the guideline separates postoperative vomiting (POV) from nausea (often difficult to assess in younger children) and recommends validated pediatric risk tools (VPOP and POVOC). Pediatric prevention emphasizes propofol-based techniques (TIVA or adjunct propofol), adequate hydration strategies (with recognition of heterogeneous evidence), and evidence-based pharmacologic prophylaxis—most strongly supporting ondansetron and dexamethasone, often in combination for higher-risk children. The guideline is cautious about routinely escalating to three or more prophylactic drugs in pediatric patients due to limited supportive evidence, instead prioritizing mitigation of baseline risks (eg, avoiding emetogenic anesthetic choices, minimizing opioids, using regional techniques when feasible).
Across all settings, the guideline highlights implementation: standardized protocols, reminders, pathway integration (ERAS/ERP), equitable care delivery, and institutional attention to adherence and outcomes. It also outlines a research agenda focused on genomics/pharmacogenomics, inflammation markers, GLP-1 receptor agonists and PONV risk, technology/AI-enabled prediction and follow-up, better patient-reported outcomes, and health economics.
What You Should Know:
• PONV prevention works best as a system: risk assessment + baseline risk reduction + multimodal prophylaxis + class-switch rescue.
• The field is shifting toward broader multimodal prophylaxis because real-world adherence and risk capture are imperfect.
• PDNV is a separate, high-impact problem; high-risk patients benefit from longer-acting strategies before discharge.
• In pediatrics, validated vomiting-focused risk scores and combination prophylaxis (ondansetron + dexamethasone) are central, while routine 3+ drug prophylaxis remains weakly supported.
Key Points:
• Use validated risk tools (Apfel for adults; VPOP/POVOC for children) but recognize limitations in real-world application.
• Reduce baseline risk with propofol-based anesthesia, opioid-sparing multimodal analgesia, and appropriate regional/neuraxial techniques.
• Adults: multimodal prophylaxis (often ≥2 interventions) is recommended for most patients with any meaningful PONV risk.
• Rescue: choose a different antiemetic class than used for prophylaxis; avoid re-dosing long-acting agents in PACU.
• Implementation, standardization, and equity are essential to reduce undertreatment and improve outcomes.
Thank you to Anesthesia & Analgesia for publishing this executive summary and helping disseminate practical, evidence-based guidance that supports consistent, multidisciplinary prevention and treatment of PONV and PDNV.