Prevention and Treatment of Post-operative Vomiting in Children

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Why?
  • Postoperative vomiting is approximately twice as frequent among children as adults with an incidence of 13 to 42% in all paediatric patients.

  • It is one of the leading causes of parental dissatisfaction after surgery and the leading cause of unanticipated hospital admission

Treatment of established Post-operative Vomiting in Children

IV ondansetron 0.15 mg/kg (maximum 4mg) should be given to children who have not already been given ondansetron for prophylaxis of POV

Ondansetron

  • There is no evidence demonstrating a benefit of timing ondansetron administration in children with respect to the time of surgery
  • If required in patients under six months a dose of 0.1 mg/kg should be used
  • Ondansetron and other 5HT3 antagonists should be avoided in children where prolonged QT interval is known or suspected

For children who have already been given ondansetron a second antiemetic from another class should be given, such as:

  • IV dexamethasone 0.15mg/kg by slow injection
  • IV droperidol 0.025mg/kg (maximum dose 1.25mg)

Drug should be diluted and given by slow IV injection if the child is awake

Dexamethasone

  • Effective anti-emetic in children on its own and in combination with 5HT3 antagonists.
  • Multiple small studies have investigated the effect of the dose for PONV - higher doses were associated with no further reduction in PONV and had a higher rate of side effects
  • IV dexamethasone may cause perineal warmth and should be injected slowly in the conscious child
  • Dexamethasone should not be used in patients at risk of tumour lysis syndrome

Droperidol

  • Used as an antipsychotic and anti-emetic drug for several decades
  • Has sedative effects, prolongs the QT interval and can cause extra-pyramidal symptoms
  • Effective anti-emetic and relieves nausea singly and in combination. It can be used both as prophylaxis and as rescue therapy.
  • Should be diluted in 0.9% NaCl and given as a slow IV bolus
  • The use of droperidol is generally confined to rescue therapy or as a second line agent, rather than prophylaxis because of the concerns around sedation and extra-pyramidal side effects
  • Contraindicated in patients with known long QT syndrome.
Reference

Martin S, Baines D, Holtby H & Carr A. Guidelines on the Prevention of Post-operative Vomiting in Children. APAGBI. 2016.

Editorial Information

Last reviewed: 30 April 2021

Next review: 30 April 2023

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Consultant Anaesthetist

Document Id: TAM471