Continuum-based postoperative nausea and vomiting prophylaxis protocol: Development and real-world implementation checklist

INTRODUCTION Postoperative nausea and vomiting (PONV) are among the most distressing postoperative complications, affecting up to 30% of all surgical patients and up to 80% of high-risk individuals.[1,2] While operating room and post-anaesthesia care unit (PACU) protocols effectively manage early-phase PONV, gaps emerge during transitions to the ward or intensive care unit (ICU).[3,4] These discontinuities prolong recovery, increase costs and reduce patient satisfaction.[5] Multimodal strategies for PONV prophylaxis are effective,[6,7] but inconsistent implementation limits their impact. To address this, we developed the continuum-based PONV prophylaxis protocol (CBPPP), a stepwise protocol covering the entire perioperative continuum, and designed a checklist for clinical application. METHODS Protocol development CBPPP was developed as follows: Literature review A systematic review of guidelines, systematic reviews, meta-analyses and primary studies on PONV prevention was conducted by two authors (MPS and AJ) [Supplementary Figure 1]. Databases such as PubMed, Cochrane Library, Scopus and Embase were searched. The complete search strategy for the literature review for each of the databases and a list of inclusion and exclusion criteria are available in Supplementary Tables 1 and 2, respectively. Priority was given to studies published in the last decade for up-to-date evidence. The Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting[3] served as a critical reference for evidence on antiemetic pharmacotherapy and perioperative interventions. Supplementary Figure 1: Flow diagram of the study selection process Supplementary Table 1: Search strategy for literature review Supplementary Table 2: Inclusion and exclusion criteria Synthesis of evidence Two authors (MPS and SB) synthesised data to identify PONV risk factors, antiemetic strategies and adjunct measures for intraoperative and postoperative care, informing stratified approaches tailored to varying risk levels. Drafting the protocol The protocol was structured into four key stages: Risk stratification: A comprehensive tool was developed to classify patients into low, moderate and high risk based on history, surgery type and anaesthetic agents. Prophylactic antiemetic selection: Risk-specific antiemetic regimens were designed, incorporating serotonin receptor antagonists, dopamine receptor antagonists, corticosteroids and neurokinin-1 receptor antagonists. Intraoperative modifications: Recommendations included avoiding volatile anaesthetics and nitrous oxide for high-risk patients and utilising regional anaesthesia when possible. Postoperative monitoring: A monitoring framework or symptom evaluation and rescue therapy were introduced. Multidisciplinary input The initial protocol draft was shared with a multidisciplinary team comprising anaesthesiologists (AG), surgeons (SB) and clinical pharmacologists (MPS). Their feedback focused on practicality, feasibility and potential barriers to implementation. Future validation plan CBPPP is a proposed framework requiring future validation. Prospective studies and randomised controlled trials will be essential to evaluate its efficacy, feasibility and impact on patient outcomes. A complementary checklist enhances CBPPP’s integration into clinical workflows, ensuring a standardised approach. Further validation is needed to confirm its impact. Proposed CBPPP Preoperative phase[4,6–12]Risk assessment:Assess PONV risk using validated tools like the Apfel score, focusing on key risk factors such as female gender, nonsmoking status, prior PONV/motion sickness and opioid use.Prophylaxis planning[4]: Low risk (Apfel score 0–1): Minimal prophylaxis Moderate risk (Apfel score 2–3): Single or dual-agent prophylaxis (e.g. dexamethasone and/or 5-Hydroxytryptamine Type 3 (Serotonin) Receptor (5-HT3) antagonist) High risk (Apfel score ≥4): Multimodal prophylaxis (e.g. dexamethasone, 5-HT3 antagonist, Neurokinin 1(NK1) receptor antagonist, scopolamine patch) Patient education: Educate the patient on PONV risk and prevention strategies.Intraoperative phase[6,7,10–12] Dynamic monitoring: Continuously reassess PONV risk during surgery, adjusting interventions as necessary. Antiemetic administration: Administer dexamethasone [8–10 mg intravenous (IV)] at induction and ondansetron (4 mg IV) before emergence. In high-risk patients, apply a scopolamine patch. Anaesthesia modifications: Minimise opioid use; favour multimodal analgesia (e.g. non-steroidal anti-inflammatory drugs, acetaminophen). Enhance antiemetic support if volatile anaesthetics are used. Postoperative phase- PACU phase[6,7,10–12] Immediate reassessment: Once the patient enters PACU, immediate evaluation of their response to antiemetics is critical. If symptoms persist or worsen, further interventions, including alternative antiemetics or rescue therapies, should be considered. Monitoring and rescue: Assess PONV severity in PACU using a standardised scale (0–3). For moderate-to-severe PONV, administer rescue antiemetics (e.g. ondansetron or aprepitant). Hydration: Maintain adequate hydration to mitigate PONV and facilitate recovery. Delayed management: Monitor for delayed PONV over 24 h, adjusting prophylaxis as needed. Ward/ICU phase[6,7,10–12] Continuity of care: Upon transferring to the ward or ICU, patients should undergo a re-evaluation of their PONV risk. Factors such as opioid use, hydration status and delayed mobilisation can increase the likelihood of PONV recurrence. Clinicians should adapt the treatment plan to address these evolving risks. Patient education: Educate patients on recognising and reporting PONV symptoms. Documentation: Record PONV protocols in the electronic health record to ensure continuity of care during handovers. Discharge and follow-up phase Extended monitoring: High-risk patients should receive follow-up care to address residual PONV symptoms. Home care guidance: Provide detailed discharge instructions on antiemetic use and when to seek medical attention. Checklist for CBPPP implementation To ensure an evidence-based approach to managing PONV, we have developed a consolidated framework that integrates risk stratification, prophylactic measures, rescue protocols and tailored antiemetic options. Table 1 serves as a practical guide for clinicians to personalise interventions based on individual patient risk profiles and clinical scenarios. Supplementary Table 3 also serves as a stepwise guide for implementing CBPPP, ensuring a systematic and evidence-based approach to PONV management.Supplementary Table 3: Comprehensive risk assessment, management protocol and antiemetic options for PONV6-12Table 1: Checklist for CBPPP implementationImplications for practice and future research CBPPP addresses care gaps in PONV management by offering a structured, adaptable framework. Prospective studies should validate its efficacy and explore its long-term benefits and cost-effectiveness across diverse surgical populations and settings. CONCLUSION Discontinuities in PONV management beyond PACU represent a critical gap in perioperative care. By adopting CBPPP, healthcare teams can enhance patient outcomes, improve satisfaction and reduce costs. The protocol’s emphasis on multimodal strategies, dynamic monitoring and patient education promotes a proactive approach to PONV management. Future research is essential to validate this framework and ensure its integration into standard perioperative practice. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.