This guideline was written by the staff of the Children's Pain Management Service (CPMS) for the Royal Children's Hospital, Melbourne.

This guideline may NOT be suitable for use in other institutions. 

Background

The cause of postoperative nausea and vomiting (PONV) is the complex mechanical and chemical interactions between the brain (vomiting centre, chemoreceptor trigger zone and middle ear) and gastrointestinal tract (Kovac, 2021).

Nausea and vomiting are unpleasant experiences which are rated by patients to be as distressing as pain. PONV is a common recognised complication of general anaesthetic/surgery and the perioperative use of opioids.

PONV is multifactorial in children due to the patient's history of previous motion sickness or PONV, the surgery type, the anaesthetic type, and agents used, length of surgery, length of fasting time, analgesic and antiemetic medications and techniques employed, the presence of pain, as well as psychological distress.

PONV can delay recovery and discharge from hospital, increasing resource utilisation, costs, and the burden on both patients and their families.

Combinations of antiemetic medications or interventions appear to be more effective than a single agent. A combination of 5HT3 receptor antagonist ("tron") and dexamethasone given as prophylaxis has shown that less rescue antiemetics were required (Schug et al., 2020).

There is a recommendation for perioperative prophylaxis antiemetics based on patient age, surgery type, anaesthetic agents and previous history (Gan et al., 2020).

Risk factors which could increase PONV incidence

Risk Factors 

Age > 3, Past history of or family history of PONV, History of motion sickness, Post-pubertal female, Preoperative anxiety

Surgery type

Strabismus surgery, Otoplasty, Adenotonsillectomy, Surgery requiring postoperative inpatient (vs day) stay, Volatile anaesthesia

Guidelines for intraoperative prophylaxis for PONV

For children >2 years who will undergo surgery requiring postoperative analgesia infusions with potential risk of PONV, CPMS recommend a minimum of two antiemetic interventions intraoperatively.

Eg: dexamethasone at induction and propofol supplemental infusion or total intravenous anaesthesia (TIVA) or 2nd antiemetic agent at surgery completion.

Guidelines for PONV rescue treatment

Antiemetic options depend on what has been given intra- and postoperatively.

Recommendations below are local to RCH and incorporate cost considerations:

• Trons

  IV options:
  

  Ondansetron

  IV 0.1mg/kg 8hourly, usual maximum 4mg (8mg may be prescribed in resistant PONV)
  

  Granisetron

  IV 0.04mg/kg daily, usual maximum 1mg dose (twice daily may be prescribed in resistant PONV)
  (Granisetron prescription is limited to Anaesthetic OR Children's Pain Management Service (CPMS) Consultants, Fellows and Registrars)
  
  
  SL/PO route:
  

  Ondansetron

  SL disintegrating tablet or PO tablet 0.1mg/kg, usual maximum dose SL 4mg and PO 8mg
  
  

• Metoclopramide

  IV or PO 0.15-0.2mg/kg 6 hourly, usual maximum dose 10mg/dose
  Consider for bilious vomiting; only continue if effective
  
  Note the RCH PONV guideline dosing for metoclopramide differs from the TGA and AMHC recommendations and RCH patients should be dosed as per this guideline.
  
  

• Droperidol^*

  IV 0.01 mg/kg 8 hourly, usual maximum 0.625mg/dose
  Consider as 3rd line for children 10 years or older; 4th line for children younger than 10 years of age
  
  * ECG monitoring is not a requirement for low dose (0.01mg/kg) administration for PONV
  
  

• Promethazine

  IV 0.5 mg/kg 8 hourly usual, maximum 25mg/dose
  Consider as 3rd line for children less than 10 years of age; 4th line for children 10 years of age or older
  
  Note the RCH PONV guideline dosing for promethazine differs from the TGA and AMHC recommendations and RCH patients should be dosed as per this guideline. This includes infants and children less than 6 years old.
  
  

Additional notes:

• At RCH, cyclizine is the most expensive antiemetic and requires Drug Usage Committee approval to prescribe
• Clonidine may be prescribed for its antiemetic and anxiolytic effects in infants and children

References

Kovac, A.L. (2021). Postoperative nausea and vomiting in pediatric patients. Paediatr Drugs, 23(1):11-37. doi: 10.1007/s40272-020-00424-0

Gan, T.J., Belani, K.G., Bergese, S., Chung, F., Diemunsch, P., Habib, A.S., Jin, Z., Kovac, A.L., Meyer, T.A., Urman, R.D., Apfel, C.C., Ayad, S., Beagley, L., Candiotti, K., Englesakis, M., Hedrick, T.L., Kranke, P., Lee, S., Lipman, D., Minkowitz, H.S., Morton, J., Philip, B.K. (2020). Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg, 131(2):411-448. doi: 10.1213/ANE.0000000000004833

Schug, S.A., Palmer, G.M., Scott, D.A., Alcock, M.M., Halliwell, R., Mott, J.F. APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2020). Acute pain management: Scientific evidence (5th edition). http://hdl.handle.net/11055/1071


First version written 1999, Updated April 2025