Some years ago, an editorial accompanying a research article targeting the prevention of postoperative nausea and vomiting (PONV) expressed the mental attitude many clinicians have in mind when PONV and its extinction are addressed: ‘we’re tired of waiting’.1 This was 1 year after the publication of the first revision of an international guideline on the management of PONV under the auspices of the SAMBA (Society for Ambulatory Anesthesia)2 and 8 years after Phil Scuderi had demonstrated that the use of a multimodal antiemetic strategy prevented early PONV after outpatient laparoscopy.3 This latter achievement is not only worthwhile to mention in terms of the reduction or even elimination of an outcome sometimes considered a secondary endpoint and being as old as anaesthesia itself but may also be valued by our patients in terms of an increase in their satisfaction.4
In 2012, when Habib and Gan5 reflected what has been achieved in the management of PONV they concluded that ‘we have moved from almost an 80% incidence in the ether and chloroform era to an overall 20%–30% incidence nowadays’. We, however, agree with Lichtor and Chung,6 and feel that a true leapfrog has not yet taken place in the management of PONV; a 20 to 30% incidence of PONV cannot be our ultimate target and recent editorials have expressed the view that ‘we still can do better’. To date, the opportunity still exists to transform PONV – the ‘big little problem’ of the 1990s7 – to the ‘big little opportunity’ for enthusiastic anaesthesiologists.8
What could be the reason for such a disillusioning state of affairs, taking into account that PONV (apart from postoperative pain) remains one of the best investigated complications of modern anaesthesia? Authors have speculated that one of the reasons that PONV has remained a challenge is the rather conservative uptake of strategies to tackle this problem, taking into account the barriers and constraints of a busy clinical environment. That means these strategies not only have to prove efficacy but also effectiveness. Many clinicians still focus their interest on PONV risk factors and the efficacy of antiemetics in isolation, whereas a clear global PONV prevention strategy, precisely adapted to the local institution, is often disregarded or incompletely implemented.
Although it is clear that the cautious use of prophylactic antiemetics may be suitable for a clinical study or a less busy clinical environment, this practice often does not work sufficiently well in real-life situations, wherein anaesthesiologists have multiple other responsibilities in addition to calculating the PONV risk score and giving the appropriate number of scheduled antiemetics. There is accumulating evidence that the implementation of a strictly risk-based approach with no PONV prophylaxis for low-risk populations may not prove effective.9–11 This is not only true for sophisticated algorithms and measures but also for simple rules of thumb, wherein any additional risk factor necessitates one additional antiemetic intervention.12
Clearly, it may be argued that reminder systems could increase guideline compliance and thus help the delivery of sufficient PONV prophylaxis.13,14 This system, however, may not represent optimal practice bearing in mind that modern antiemetics are relatively inexpensive and have been extensively studied in well conducted clinical trials that have demonstrated excellent side effect profiles. We would like to question whether the notion that the ‘use of prophylactic antiemetics should be based on valid assessment of the patient's risk for POV or PONV’, contained in the first revision of the SAMBA guidelines,2 may have contributed, at least in part, to the fact that anaesthesiologists have been reluctant to administer two or even more prophylactic antiemetics on a regular basis. The second version of the SAMBA PONV guideline further elaborates, stating that ‘antiemetic prophylaxis should be used only when the patient's individual risk is sufficiently high’. This advice may have contributed to the aforementioned reluctance and have inhibited anaesthesiologists from the more liberal use of antiemetic prophylaxis.
Thanks to a more comprehensive literature search strategy and a greater focus on more contemporary research studies, recently published guidelines15 contain comprehensive data on established and new agents in addition to combination (multimodal) prophylaxis. Furthermore, on the basis of implementation research, two new guidelines complete the consensus recommendations.
First, it has been agreed that measures must be put in place to determine whether suggested algorithms for the management of PONV are actually implemented as standard operating procedure in clinical settings, and that these practices lead to improved PONV management. This ‘Guideline 7’ has been introduced to emphasise the importance of actually implementing PONV prevention and treatment strategies in the clinical setting and to examine whether these measures actually work.15 Second, the group supported the notion that, in light of the poor guideline compliance with risk-adapted approaches and no general preventive measures, multimodal prevention strategy (adjusted with additional measures in high-risk patients) may be an option to facilitate clinical implementation.15 This latter recommendation acknowledges that a multimodal preventive approach may well be justified in order to facilitate the implementation of PONV prevention strategies. We are aware that these recommendations are not rock-solid science in terms of direct supporting evidence of superiority versus a strictly risk-adapted approach, and one may argue that these proposed approaches should first undergo validation in randomised trials. We should bear in mind, however, that there are only a limited number of adverse outcomes we may attack in such an effective way. We should not miss this opportunity to try and improve patient experience in terms of PONV prevention. We should also be aware that each additional antiemetic intervention actually adds benefit in terms of a decreased incidence of PONV. Clearly, it can be argued that based on a calculated number-needed-to-treat, this benefit must be balanced against any unnecessary exposure,16 but we strongly believe that the ultimate goal has not been achieved if we have to state that ‘we have moved … to an overall 20–30% incidence nowadays’.5 There is still a long and winding road ahead of us and, to be honest, it is unlikely that we will succeed without the more liberal use of antiemetic agents.
During the last few years, much has been written about PONV and much of the evidence has been published in this journal.17–20 Additional evidence will be gathered in ongoing clinical trials,21 but the most challenging hurdle we may actually face is the implementation of that knowledge. The search for molecules with different targets will go on and there is still a need for additional components and drug therapy with improved side effect profiles.22
Although this may be viewed as the task of a few clinical researchers, implementation is the task we all have to face at our working places. Each of us should contribute to the fact that the next ‘Then and Now’ series on PONV5 should end with the sentence that PONV is now just an unmanageable problem for a tiny fraction (perhaps less than 5%) of patients and does not represent a threat to the majority of them! For this reason, we simply may change our approach from a rather conservative PONV prevention to a more liberal one. This shift in paradigm is backed up by good evidence and is already nicely documented in two statements by Phil Scuderi, who in 1999, while writing about patient satisfaction after treatment as opposed to single antiemetic prevention, stated that ‘although PONV is unpleasant, the data indicate little difference in outcomes when routine prophylactic medications are administered versus simply treating PONV should symptoms occur’.23 Some years later, in an editorial, he came to the conclusion that ‘given the extremely low cost of all the currently available generic antiemetics and the extremely low incidence of adverse side-effects, I would suggest that all patients might benefit from three or more antiemetics during the course of surgery to reduce the incidence of PONV as much as possible’.24
We would welcome such a step, although we do not want to suggest a specific (i.e. three or more) number of antiemetics that need to be given and we also acknowledge that more risk-aware and stratified approaches may well work to tackle PONV in specific circumstances and settings. However, just as anaesthesiologists have come to regard postoperative pain as undesirable and treatable, we should strive to do the same for PONV. Along with ongoing clinical studies, we advocate implementation studies reporting attempts to achieve the ‘PONV-free hospital’.25,26
We firmly believe, as it is expressed in the concluding remarks of the updated PONV guidelines, that ‘there are significant challenges in implementing an institution-wide, comprehensive PONV prevention protocol based on a detailed patient and institution risk-adapted approach’.15 In addition, we, as European contributors to the revised guideline that has been endorsed by the European Society of Anaesthesiology, are convinced that ‘a more practical risk assessment using a more liberal preventive strategy may be a better alternative in a busy clinical environment such that it becomes an integral part of anaesthesia’.15 If we achieve that, and PONV prophylaxis becomes an integral part of anaesthesia, the end of this winding road could be nearer than we might think!
Acknowledgements relating to this article
Assistance with the editorial: we appreciate the contributions of the Language Editing and Martin Tramèr, EIC of the European Journal of Anaesthesiology and also member of the Consensus Guideline Committee, for constructive comments.
Financial support and sponsorship: this work was supported by the Department of Anaesthesia and Critical Care, University Hospitals of Würzburg, Germany and the Service d’Anesthésie-Réanimation Chirurgicale, Hôpitaux de Hautepierre, Strasbourg, France.
Conflicts of interest: PK was a member of the consensus panel of the international guideline on the management of PONV. He has been primary investigator of various clinical studies on the prevention and treatment of PONV, including phase II and III trials of Acacia Pharma Ldt., UK, GlaxoSmithKline, US, and FreseniusKabi. Germany. He has received lecture fees from FreseniusKabi Germany and Merck. PD was a member of the consensus panel of the international guideline on the management of PONV. He has been primary investigator of various clinical studies on the prevention and treatment of PONV, including phase II and III trials of Acacia Pharma Ldt., UK, GlaxoSmithKline, US, and FreseniusKabi, Germany. He has received lecture fees, consultant fees and his institution has received research grants from ProStrakan, France, Glaxo, UK, and Merck, US.
Comment from the Editor: this editorial was checked by the editors but was not sent for external peer review. PK and PD are associate editors of the European Journal of Anaesthesiology.
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