Anesthesia Patient Safety Podcast
The official podcast of the Anesthesia Patient Safety Foundation (APSF) is hosted by Alli Bechtel, MD, featuring the latest information and news in perioperative and anesthesia patient safety. The APSF podcast is intended for anesthesiologists, anesthetists, clinicians and other professionals with an interest in anesthesiology, and patient safety advocates around the world.
The Anesthesia Patient Safety Podcast delivers the best of the APSF Newsletter and website directly to you, so you can listen on the go! This includes some of the most important COVID-19 information on airway management, ventilators, personal protective equipment (PPE), drug information, and elective surgery recommendations.
Don't forget to check out APSF.org for the show notes that accompany each episode, and email us at podcast@APSF.org with your suggestions for future episodes. Visit us at APSF.org/podcast and at @APSForg on Twitter, Facebook, and Instagram.
Anesthesia Patient Safety Podcast
#287 A New Era For PONV: Safety, Guidelines, And Smarter Rescue
Nausea shouldn’t be the most memorable part of surgery. We take a clear, evidence-based look at postoperative nausea and vomiting, from identifying who’s at risk to building smarter prophylaxis bundles and choosing the right rescue when prevention falls short. With guest insights from Dr. Connie Chung, we unpack the Fourth Consensus Guidelines, translate them into practical workflows, and explore how Amisulpride—an atypical D2 antagonist—changes the game with an FDA indication for rescue after failed prophylaxis.
We start by shrinking baseline risk: consider regional anesthesia when feasible, leverage TIVA with propofol, avoid nitrous and volatiles in longer cases, hydrate well, and spare opioids with multimodal analgesia. Then we scale prophylaxis to risk: dexamethasone at induction, 5-HT3 antagonists at the end, transdermal scopolamine for select patients, and low-dose Droperidol where appropriate. When prophylaxis fails, we explain why repeating ondansetron rarely helps and how switching classes boosts rescue success. Along the way, we map the safety terrain for D2 antagonists—QT prolongation, extrapyramidal risks, anticholinergic effects—so you can individualize care for elderly patients, those on antipsychotics, or anyone with potential drug interactions.
We also dig into what’s new: contemporary analyses of Droperidol at antiemetic doses, and growing evidence that Amisulpride pairs well with Ondansetron or Dexamethasone to improve outcomes. Pediatric pearls include TIVA, fluids, and a two-drug prophylaxis backbone for longer or higher-risk cases. The result is a practical, stepwise approach you can apply tomorrow—reduce risk, layer mechanisms, and rescue smartly—to cut PACU delays, avoid unplanned admissions, and deliver a recovery that feels as good as the surgical fix.
If this deep dive helps your practice, follow, share with your team, and leave a quick review to help others find the show. Tell us your go-to PONV bundle and whether your site stocks Amisulpride.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/287-a-new-era-for-ponv-safety-guidelines-and-smarter-rescue/
© 2025, The Anesthesia Patient Safety Foundation
Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. We are returning to two of our most popular episodes of all time to bring you a special revisited show today. Our conversation covers one of the most important topics for anesthesia professionals and our patients. This is a topic that may come up during a preoperative interview, something that may alter our anesthesia plan interoperatively, and is a postoperative complication that may delay discharge from the PACCU. So stay tuned. Before we dive into the episode today, we'd like to recognize GE Healthcare, a major corporate supporter of APSF. GE Healthcare has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, GE Healthcare. We wouldn't be able to do all that we do without you. Have you figured out what we're talking about today? That's right, it is Postoperative Nausea and Vomiting. Our featured article is Dopamine Antagonist Antimedics in Post Op Nausea Vomiting Management, Entering a New Era by Connie Chung and Joseph Skokel from the February 2023 APSF newsletter. To follow along with us, head over to APSF.org and click on the newsletter heading. The fourth one down is Newsletter Archives. From here, scroll down to the February 2023 newsletter and our featured article today. I will include a link in the show notes as well. And now let's return to episodes number 141 and 142 all about postoperative nausea and vomiting management. Here we go. Before we get into the article, we are going to hear from one of the authors, Connie Chung. Let's take a listen.
SPEAKER_01:Hi, my name is Connie Chung, and I'm an anesthesiologist at the University of Southern California, Keck School of Medicine in Los Angeles, California. I'm also the medical director of our outpatient surgery center.
SPEAKER_00:To kick off the show today, I asked her why she wrote this article. Here's what she had to say.
SPEAKER_01:Postoperative nausea and vomiting, or PONV for short, is a topic I'm very passionate about. We want all of our patients to have a great perioperative experience, and PONV can really leave a bad taste in your mouth. All jokes aside, PONV also contributes to prolonged recovery room stays, unanticipated hospital admissions, and increased health care costs. Moreover, as a non-smoking female who experiences motion sickness, I know that I personally am in the highest risk category for PONV. It is exciting to see that there is now an FDA-approved agent that can be used as rescue treatment of POMV after failed prophylaxis.
SPEAKER_00:It is really exciting to see a new medication that can be used for treatment of PONV. Before we head into the new era for PONV treatment, let's review where we have been. The authors remind us that dopamine, D2 receptor antagonists, were the primary treatment for postoperative nausea and vomiting for the second half of the last century. Then, at the start of the 21st century, the use of these medications decreased due to safety concerns as well as the publication of a black box warning by the U.S. Food and Drug Administration on Droperidol, which was the most commonly used dopamine D2 receptor antagonist. Have you used Droperidol for the management of PONV in your practice? Did your practice change after the black box warning? There is a new kit on the block for the treatment of PONV. In 2020, the FDA approved a missile pride for the prevention and treatment of PONV, and it is the only approved agent for rescue treatment after failed prophylaxis. One of the things we have learned about D2 antagonists is that even drugs that are in the same drug class have different safety and efficacy profiles. There are at least three distinct structural subclasses with a different pharmacologic properties and side effects. The subclasses include substituted benzamides, butyrophenones, and phenothiaes. Check out table one in the article. It includes the subclasses, the prototypical agent, key pharmacologic properties, important side effects, and noteworthy considerations. We are going to review it now. First up is the benzamides group, and thislepride belongs to this subclass. Key properties include the following: low CNS penetration as well as low affinity for potassium channels and cholinergic, adrenergic, and histamine receptors. The important side effects include mild prolactinemia and low incidence of extrapyramidal symptoms. Finally, benzamides are FDA approved for use in PONV management. Next up is the butyraphenones, which includes droperidol. Droperidol has high CNS penetration and a high affinity for potassium channels. Side effects include sedation, acathesia, and QT prolongation. Key considerations include the black box warning, and low doses are effective in post-op nausea and vomiting management. The third subclass is phenothiazines. Prochlorperizine belongs to this class. Key properties include high affinity for cholinergic, adrenergic, and histamine receptors. Side effects include sedation, extrapyramidal symptoms, urinary retention, and orthostatic hypotension. Administration of this drug to elderly patients may not be appropriate due to these side effects and safety concerns. Speaking of safety, the authors highlight the safety profile of D2 antagonists. The early D2 antagonists include neuroleptics and first generation antipsychotics. There was a wide range of neurological effects, ranging from sedation to neuropsychiatric, including dysphoria or cognitive impairment due to central nervous system penetration. Another considerable side effect included extrapyramidal symptoms such as tardive dyskinesia, dystonia, and akathisia, which limited its use. Don't forget about the risk of neuroleptic malignant syndrome, or NMS. Patients may present with fever, mental status changes, muscle rigidity, autonomic instability, and hyperprolactinemia from blockade of D2 receptors in the pituitary gland. There are cardiac side effects as well, since binding to potassium ion channels may lead to QT prolongation and torsodsta points. The newest medication, emissal pride, is considered to be atypical or a second generation antipsychotic with decreased CNS penetration and decreased adverse effects. It is important to keep in mind that some of the side effects from D2 antagonists are dose dependent, but just decreasing the dose may not be the answer, since there is limited data about dose reduction and efficacy. There may be a significant impact on patient safety due to the adverse reactions such as tardive dyskinesia, dysphoria, and torsad depoints. Let's move on to talk a little bit more about each of the different classes of medications, and we are going to start with the benzamides. Remember, this is the drug class that emissalpride is in. Droperidol is in this class and historically was administered in low doses for first-line treatment for PONV. Side effects include sedation, dysphoria, anxiety, acathhasia, and QT prolongation. You are probably already aware of the risk of QT prolongation since the FDA applied a black box warning in 2001 due to this risk leading to sudden cardiac death. After the black box warning, droperidol administration for PO and V prophylaxis declined significantly. Recently, a new study, the 2020 Cochrane Network Meta-analysis, revealed that antiemetic doses of droperidol had a similar incidence of adverse events when compared to placebo. The most common doses for droperidol in this study included 0.625 to 1.25 milligrams IV given at induction of anesthesia. After the FDA black box warning was placed on Droperidol, the focus shifted to haloperidol, another butyrophenone medication that may be used for treatment of PONB. Adverse side effects include sedation, extraperimidal symptoms, neurotoxicity, and QT prolongation. In 2007, the FDA updated the labeling for haloperidol to remind clinicians that this medication is not approved for IV administration for PONV treatment, and its use in high doses is associated with torsad de points and QT prolongation. Keep in mind that a single low dose of IV haloperidol may be used for PONV prophylaxis and is likely safe and effective. The third subclass is phenothiazines. Prochlorperazine is the most common medication in this class for PONV management. Adverse effects include the following sedation, extraperimidal symptoms, anticholinergic effects such as anorexia, blurred vision, constipation, dry mucosa, and urinary retention, antiadrenergic effects leading to orthostatic hypotension, and decreased seizure threshold. Another phenothiazine, D2 antagonists, is promethazine, which also has antihistamine effects and may produce sedation. Caution must be used with IV administration since severe tissue damage may occur following extravasation from a vein. Now that we have reviewed the different subclasses, let's talk about side effects from D2 antagonists. Remember, the D2 antagonists are not recommended to be used for patients with prolonged QT syndrome or in combination with other medications that prolong the QT interval. The FDA black box warning on droperidol highlighted the risk for QT prolongation. But the authors remind us that oncitron, which does not have a black box warning and is commonly used antimedic medication, can also prolong the QT interval. But the QT prolongation from the combination of onansitron and Droperidol is not longer than that induced by either drug alone. There are several home medications that may lead to significant adverse effects when D2 antagonists are administered during the perioperative period. Be on the lookout for QT prolongation when D2 antagonists are administered for patients taking medications that either reduce the heart rate or induce hypokalemia. Patients taking antipsychotic medications are at risk for tardive dyskinesia and NMS. Do not administer D2 antagonists to patients taking dopamine agonists, including levadopa for Parkinson's, or carbergaline for hyperprolactinemia. It is also important to avoid co-administration with monoamine oxidase inhibitors, since norepinephrine is broken down by MAO and the D2 blockade leads to buildup of norepinephrine and an exaggerated end organ response. One of the APSF priorities is perioperative brain health, which includes perioperative delirium, cognitive dysfunction, and brain health. This is an important consideration with the use of D2 agonists. The authors advise caution with or avoidance of administration of D2 antagonists for PONV management in patients older than 65 years old due to the risks of central anticholinergic effects. This is the phenothiazine subclass, extraperimidal symptoms from the benzamides, and tardive dyskinesia, delirium, and NMS from the butyrophenones. There is an increased risk for cerebrovascular accident, cognitive dysfunction, and mortality in elderly patients who receive these medications. But you must also remain vigilant in pediatric patients who may develop extraperimidal symptoms or QT prolongation following administration of D2 antagonists. There is still more to talk about related to D2 antagonists and post-op nausea vomiting management. So we're gonna continue on with episode number 142. We promised you a supersized episode today, so let's keep the conversation going as we discuss PONV clinical practice guidelines. Let's take a step back from the treatment of PONV to talk about postoperative nausea and vomiting in general. Postoperative nausea and vomiting, or PONV, is an important consideration for anesthesia patient safety that may have a big impact on prolonged post-anesthesia care unit length of stay, unanticipated hospital admissions, and increased health care costs. Recently, in 2020, the Fourth Consensus Guidelines for the Management of PONV was published, which outlines identification of high-risk patients, managing baseline PONV risks, choices for prophylaxis, and rescue treatments for post-apnause and vomiting. The authors highlight two important considerations from the guidelines. First, prevention of PONV must be a critical component of anesthesia care, and patients with even just one or two risk factors for PONV should receive multimodal PONV prophylaxis. Let's take a quick commercial break to review the risk factors for PONV from the fourth consensus guidelines, which includes the following female sex, history of PONV or motion sickness, nonsmoking, younger age, general versus regional anesthesia, use of volatile anesthetics and nitrous oxide, postoperative opioids, duration of anesthesia, and type of surgery, including cholecystectomy, laparoscopic, and gynecological procedures. There is conflicting evidence for the following factors and the impact on PONV: ASA physical status, menstrual cycle, level of anesthesiologist experience, and perioperative fasting. Here are some factors that have been either disproven or shown to be of little clinical relevance: BMI, anxiety, presence of a nasogastric tube, history of migraines, and use of supplemental oxygen. And now back to the APSF article for the second point highlighted by the authors. Post op nausea and vomiting treatment should include the use of an antiemetic medication from a different pharmacological class than the initial prophylactic medication. That's right, there is no benefit of redosing on Dancitron, even though this is a common practice. Before we get to the Citing conclusion of the APSF article, let's review the fourth consensus guidelines a little bit more. I will include a citation in the show notes as well. Table three provides a plan to decrease the baseline risk for PONV, which includes the following steps. Avoidance of general anesthesia by using regional anesthesia. Use of propofol for induction and maintenance of anesthesia. Avoidance of nitrous oxide in surgeries that are longer than one hour. Avoidance of the use of volatile anesthetics. Multimodal analgesia with a goal to minimize interoperative and postoperative opioid administration, providing adequate hydration, and use of cigamidex rather than neostigmine for reversal of neuromuscular blockade. Table 4 in the consensus statement provides a list of antiemetic medications with the dose and timing for adults. We are going to review a few of these now. Emissal pride 5 mg given at induction. Deximethasone 4 to 8 milligrams IV given at induction. Droperidol 0.625 mg IV given at the end of surgery. Haloperidol 0.5 to less than 2 mg IM or IV, Metaclopromide 10 mg, onansitron 4 mg IV given at the end of surgery, Promethazine 6.25 mg, and scopolamine transdermal patch given the evening prior to or two hours before the procedure. There is so much great information in the fourth consensus guidelines. Let's take a look at one more graphic. Figure six is an infographic that displays an algorithm for post-op nausea vomiting management in adults. Step one is identifying risk factors. Step two is risk mitigation using some of the steps that we outlined earlier. Step three includes risk stratification, and patients with one to two risk factors should receive two agents, and patients with more than two risk factors should receive three to four agents. Step four is prophylaxis options, and step five involves rescue treatment using an antiametic from a different drug class than the prophylactic class. As we work through the algorithm for the management of PONB in adults, it is important to remember that the combination of non-D2 antagonists antiemetic medications combined with older D2 antagonists like Droperidol, Haloperidol, and promethazine, are more effective than either agent alone. More recently, emissopride has been evaluated in six clinical trials. In five of these trials, emissilepride was studied as the sole antimetic drug and found to be superior to placebo for prevention and treatment of PONV. The 2018 study in anesthesiology, emissalpride prevents postoperative nausea and vomiting in patients at high risk, a randomized, double-blind placebo control trial, reported that the combination of emissal pride with onanzitron or dexamethasone was more effective than onansitron or dexamethasone alone for preventing PONV or for rescue treatment. I will include this citation in the show notes as well. Management of PONV is multifactorial, including prevention as well as management, and this is a vital component of the anesthetic plan, especially as part of the enhanced recovery after surgery pathways, for patients undergoing ambulatory surgery, and for high-risk patients with high acuity and high fragility levels. As we have talked about for the past two episodes, D2 antagonists are effective medications for post-op nausea and vomiting management. But understanding the side effects, effective doses, and route of administration is critical. The future of PO and V management is bright with a new option, a missile pride, which is a D2 antagonist with less side effects and excellent efficacy for prevention and rescue treatment. Before we wrap up for today, we are going to hear from one of the authors of the APSF newsletter article, Connie Chung again. I asked her, what do you hope to see going forward? Let's take a listen to what she had to say.
SPEAKER_01:The prevention of PONV should be considered an integral aspect of anesthesia. However, sometimes despite our best efforts to identify high-risk patients and administer prophylaxis, patients still develop PONV. And now there's an FDA-approved treatment option for PONV with a favorable safety profile. My hope is that more patients can benefit from the use of MSL Pride.
SPEAKER_00:Thank you so much, DeChung, for contributing to the show today. We hope more patients can benefit from treatment with Emissal Pride when it comes to managing PONV going forward. We will be on the lookout for future studies and a cost-benefit analysis related to this newer medication. Do you have a missile pride at your institution? Have you used it for the management of PONV? Let us know by tagging us on Twitter at APSForg using the hashtag hashtag APSF Podcast. We made it to the end of the article, but we also need to address a threat to anesthesia patient safety for our pediatric patients. That's right, the management of PONV in children is so important. If we look at the fourth consensus statement, there are several considerations. First, reducing baseline PONV risk may include the use of TIVA, liberal fluid therapy, and opioid sparing techniques. There is some evidence that IV lidocaine, IV acetaminophen, and alpha-2 agnes as part of a multimodal anesthetic plan may help to decrease rates of PONV. Post-opnause vomiting prophylaxis in children may include administration of the following medications. Aprepatin, 3 mg per kilogram up to 125 mg, deximethasone, 150 mics per kilogram, up to 5 mg, droperidol, 10 to 15 mics per kilogram, up to 1.25 mg, and oncitron, 50 to 100 mics per kilogram up to 4 mg. Looking a little closer at the fourth consensus guidelines, the authors report that when the risk for PONV is very low and the surgery is less than 30 minutes long, PONV prophylaxis may not need to be administered. For longer surgeries or patients at high risk, prophylaxis with a combination of medications is recommended. What is your preferred PONV prophylaxis combo for pediatric patients? The strongest evidence supports administration of dexamethasone plus onansitron for prophylaxis. Thank you for joining us for this end-of-year revisited special episode edition. We'll be back in the new year with all new episodes as we continue to work towards improved anesthesia patient safety. If you have any questions or comments from today's show, please email us at podcast atapsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.