Postoperative Nausea and Vomiting in Pediatrics: Incidence and Guideline Adherence
Myron Yaster MD, Lynne G. Maxwell MD, and Lynn D. Martin MD MBA
Thirty plus years ago when ondansetron was first introduced into clinical anesthesia practice, it wasn’t clear if every pediatric patient should get it prophylactically or if it should be reserved and used only for nausea and vomiting rescue in the PACU. A world-famous pediatric anesthesiologist (I am deliberately not giving their name) was planning a randomized controlled trial at their large children’s hospital but decided against it after doing a retrospective analysis he/she performed to determine the studies “n”. He/she cancelled the study and explained why at a Society for Pediatric Anesthesia annual meeting. They called their retrospective analysis the “secret study” and never published it. What they found was that all of the children of faculty members, OR staff, and VIPs got ondansetron prophylactically and the children of the hoi polloi (i.e. the masses) only got it as rescue. They were frankly embarrassed by this finding and decided if their faculty thought ondansetron was so superior and important that it should be given to their families, then everyone should get it. Which brings us to today’s PAAD[1] and its accompanying editorial[2]. Portnoy et al. wondered “What is the incidence of postoperative nausea and vomiting (PONV) in a diverse pediatric population, and how well do current practices adhere to the latest consensus guidelines[3]?”[1]
Because guideline implementation is such an important element of today’s PAAD, I asked Dr. Lynn Martin who is the PAAD’s Quality Improvement and implementation science lead expert and a chief medical officer of AdaptX to assist. Myron Yaster MD
Editorial
Benzon HA, Belani K, Cheon EC. Postoperative Nausea and Vomiting in Children: Challenges and Some Solutions. Anesth Analg. 2025 Jul 1;141(1):74-76. doi: 10.1213/ANE.0000000000007326. Epub 2025 Feb 14. PMID: 39951389.
Original article
Portnoy Y, Glebov M, Orkin D, Katsin M, Berkenstadt H. Postoperative Nausea and Vomiting in Pediatrics: Incidence and Guideline Adherence-a Retrospective Cohort Study. Anesth Analg. 2025 Jul 1;141(1):77-85. doi: 10.1213/ANE.0000000000007291. Epub 2024 Nov 19. PMID: 39774167.
One of the great quality and safety success stories in pediatric anesthesia has been the reduction of postoperative nausea and vomiting (PONV) through the prophylactic intraoperative administration of 5-HT3 antagonists (e.g., ondansetron) and the steroid dexamethasone. The incidence of PONV had historically been reported to occur in as many as 30-80% of pediatric patients and now, Portnoy et al report in their study, it is as low as 1-4%. Wow!
How did we get here and is there still room for improvement? In pediatrics there are certain patient groups who are higher risk of developing PONV. These include patient (age > 3, history of patient or family PONV or motion sickness, being a postpubertal female), intraoperative (strabismus, adenotonsillectomy, use of volatile anesthetics, opioids and/or anticholinesterases) and postoperative long-acting opioids) factors (see figure below).
In 2020, the Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting were published.[3] Portnoy et al wondered how compliance with these guidelines would affect the incidence of PONV in children. Using the algorithm based on these guidelines reproduced in the figure below, in this retrospective study of 3,772 patients. They achieved astonishing results, PONV rates of 1% (in the PACU)-3.8% (in the first postoperative day), with room for even further improvement.
There are some very important take home messages in this study. The reduction in PONV occurred even in patients when the 4th consensus guidelines were not routinely followed. However, adherence to the guidelines reduced the occurrence of PONV more than in patients in whom the guidelines were not followed (2.7 v 4.4%, p= 0.012). And yet, adherence to the guidelines occurred in only 32.5% of patients. Which brings us back to a recurrent theme in recent PAADs. How do you actually and successfully IMPLEMENT evidence-based changes into clinical practice? (PAAD June 13, 2024 https://ronlitman.substack.com/p/implementation-science )
Detailed reviews of implementation science, including in the perioperative setting have been published.[4, 5] Rapport et al.[4] describe the foundational concepts to implementation science in five categories: diffusion (spontaneous spread of ideas, behaviors and practices), dissemination (active spreading of evidence-based interventions to targeted audiences), implementation (using research evidence applied to practice through implementation procedures), adoption (the degree of uptake of new ideas, behaviors, practices , and organizational structures), and sustainability (the logical endpoint which creates a feedback loop that demands monitoring, adoption, and extended uptake to that changes become entrenched into the culture-‘the way we do things here’).[4] Lane-Fall and colleagues cite two specific examples where they suggest application of implementation science methods could likely yield better clinical outcomes.[5] The first, much like in today’s PAAD, is the implementation of enhanced recovery after surgery (ERAS) pathways in which multimodal perioperative care programs are designed to reduce recovery time, hospital length of stay, and surgical complications. Unfortunately, meta-analyses of ERAS programs across surgical subspecialties have shown the desired reductions in length of stay and complications but also report pathway compliance rates as low as 65% (more than the 34% in today’s PAAD). Given that pathway adherence is associated with improved outcomes, it is crucial to understand the factors linked to pathway adherence. The second example of evidence-based practice is the Surgical Safety Checklist (SSC). The SSC is modeled after safety checklists used in high-reliability organizations includes multiple elements checked in one of three times during surgery: before induction of anesthesia, before skin incision, and at the end of surgery. High compliance with SSC is associated with improved risk-adjusted clinical outcomes. Despite this compelling evidence, several studies show variable compliance with all elements of the SSC. Methods of implementation science could (should) be used to increase adherence with all SSC elements; hopefully dropping the surgical complication rates.
Myron and Lynne have given you a great high-level review of implementation science. I (LDM) will try to move the discussion from the theoretical to practical domain. As commonly happens when I read new articles from the literature, I wondered how our practice in Seattle is doing relative to that reported in the publication. I spent about 1 hour completing the assessment that approximated the work of Portnoy et al and extracted the data for patients from Seattle Children’s. In our hospital (n=27,166) we saw a comparable early (PACU) PONV rate and increasing rate of dual PONV prophylaxis use (see figures below). Note the statistically significant decrease in PONV associated with increasing dual prophylaxis compliance.
In our lower acuity ASC with its more homogenous patient and procedure population (n=12,198) where we had a sustained dual PONV prophylaxis rate of 88% with a 10x lower early PONV rate. Note that our ASC is also 99.7% opioid free (as compared to 70% at the hospital).
I (LDM) was not at all surprised by the low rate of protocol compliance (32.5%) found in this study. (1) The authors describe the very limited efforts made to build compliance throughout the department (1 staff meeting and 1 journal club discussions) done 1 month after the guideline publication. Furthermore, their departmental communication left selection of prophylactic treatment to the discretion of the attending anesthesiologist. Many steps could have been taken to increase the rate of compliance. Examples include (1)provide monitoring or reporting of preliminary data to inform and motivate the department members during the study, (2) reminders in monthly staff meetings and emails, (3) EMR provider alerts and/or care templates, (4) encouragement and coaching from departmental QI leaders, and (5) gather staff feedback and use PDSA cycles to improve not just the protocol and also its compliance. It takes many conversations, frequent reminders, and monthly reporting of data to build awareness and achieve good compliance (>80%). Sadly, it has been reported that up to 70% of organizational change efforts fail to be sustained (>12 consecutive months at or above target) (6,7). This has become my (LDM) new holy grail and could be a topic for a future PAAD!
In conclusion, Portnoy et al results reflect remarkable improvements in outcomes through updates in modern anesthesia practices. However, it is also an example of why medicine is so slow to change. You can’t expect physicians to change their practice after a single publication and one or two discussions. The snapshot from Seattle shows that we can change and sustain improvements when we take the time and energy to education, engage, and motivate anesthesiologists.
How do you implement and overcome obstacles to change? Tell us what you think and share your experiences (good and bad). Myron (myasterster@gmail.com) will post your comments in a Friday reader response.
References
1. Portnoy Y, Glebov M, Orkin D, Katsin M, Berkenstadt H: Postoperative Nausea and Vomiting in Pediatrics: Incidence and Guideline Adherence-a Retrospective Cohort Study. Anesthesia and analgesia 2025, 141(1):77–85. PMID: 39774167.
2. Benzon HA, Belani K, Cheon EC: Postoperative Nausea and Vomiting in Children: Challenges and Some Solutions. Anesthesia and analgesia 2025, 141(1):74–76. PMID: 39951389.
3. Gan TJ, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS, Jin Z, Kovac AL, Meyer TA, Urman RD et al: Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia 2020, 131(2):411–448. PMID: 32467512
4. Rapport F, Clay-Williams R, Churruca K, Shih P, Hogden A, Braithwaite J: The struggle of translating science into action: Foundational concepts of implementation science. Journal of evaluation in clinical practice 2018, 24(1):117–126. PMID: 28371050
5. Lane-Fall MB, Cobb BT, Cené CW, Beidas RS: Implementation Science in Perioperative Care. Anesthesiology clinics 2018, 36(1):1–15. PMID: 29425593
6. Glascow JM, Davies ML, Kaboli PJ. Findings from a national improvement collaborative; are improvements sustained? BMJ Quality Safety 2012;21:663-9. PMID: 22491531
7. Mortimer F, Isherwood J, Wilkinson A, Vaux E. Sustainability in quality improvement: redefining value. Future Healthcare Journal 2018;5(2):88-93. PMID: 31098540