Post-operative Nausea Vomiting PONV

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

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

    For children > 2 years who are to receive postoperative analgesic infusions 

    PONV prophylaxis:

    CPMS recommends dual agents be given intraoperatively:

    • Metoclopramide 0.5 mg/kg   Maximum dose 20-30mg
    • Dexamethasone 0.15mg/kg  Maximum dose 8 mg
       

    PONV treatment / rescue therapy:

    1st line:    

    Metoclopramide LOAD
    (if NOT given intraoperatively)
    0.5 mg/kg IV (over 10 minutes)
    (Maximum dose 20 mg)

      IF EFFECTIVE, CONTINUE:
    Metoclopramide 0.2 mg/kg IV/PO q6h PRN
    (Maximum dose 20 mg)
     
    If ineffective:    
      arrow, select choice below    
    2nd line:    
    Dexamethasone
    (if not contraindicated and NOT given already)
     0.15 mg/kg IV for ONE dose
    (Maximum dose 8 mg)
      NB this agent is commonly used intraoperatively. If this is the case it should be given as a single dose on Day 2 only
     
    If ineffective:    
     arrow, select choice below    
    3rd line:    

    Granisetron 40 microgram/kg IV daily PRN  
    (Maximum dose 1mg) 
    OR
    Ondansetron0.1 mg/kg sublingualwafer q8h PRN
    (Maximum dose 4 mg)

     

    IF EFFECTIVE, CONTINUE:
    Granisetron 40 microgram/kg IV
    daily PRN  
    (Maximum dose 1mg)  
    OR
    Ondansetron 0.1 mg/kg sublingual
    wafer q8h PRN
    (Maximum dose 4mg)

    for 72 hours ONLY

        These 'trons' can ONLY be prescribed by CPMS, Anaesthesia Consultants 
    OR after approval from Drug Usage Committee (DUC)
     If ineffective:    
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    4th line [over 10 years]:    
    Droperidol10 microgram/kg IV q8h PRN
    (Maximum dose 0.625 mg)
      IF EFFECTIVE, CONTINUE:
    Droperidol 10 microgram/kg IV
    q8h PRN
    (Maximum dose 0.625 mg)
    4th line [under 10 years]:    
    Promethazine 0.5mg/kg IV q8h PRN 
    (Maximum dose 25mg)
      IF EFFECTIVE, CONTINUE:
    Promethazine  0.5mg/kg IV q8h PRN 
    (Maximum dose 25mg)
    If ineffective:    
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    5th line [over 10 years]:    
    Promethazine  0.5mg/kg IV q8h PRN 
    (Maximum dose 25mg)
      IF EFFECTIVE, CONTINUE
    Promethazine  0.5mg/kg IV q8h PRN 
    (Maximum dose 25mg)
    5th line [under 10 years]:    
    Droperidol10 microgram/kg IV q8h PRN
    (Maximum dose 0.625 mg)
      IF EFFECTIVE, CONTINUE:
    Droperidol 10 microgram/kg IV
    q8h PRN
    (Maximum dose 0.625 mg)
    arrow_down_bw_50px    
    Continued PONV?    
    CONTACT
    Children's Pain Management Service
    PAGER 5773
       
    Continued PONV?
    • If PCA in use: Consider reducing PCA bolus dose, increasing dose administraton time &/OR ceasing PCA background infusion
    • Consider removing opioid from epidural infusion
    • Change or add non-opioid medication if appropriate (e.g. tramadol, paracetamol, ketamine, NSAIDs)
    • Surgical review may be warranted to exclude surgical cause
    • Consider other agents, e.g. clonidine or midazolam infusion
       

    Other medications for PONV:

    • Midazolam Infusion for persistent vomiting:
     Weight under 25 kg
     25 mg in 50 mL diluent
     Bolus 0.5 mg
     Infusion 0.25-0.5 mg/hr
     Weight over 25 kg
     50 mg in 50 mL diluent
     Bolus 1mg
     Infusion 1mg/hr

    First version written 1999, Updated July 2014