Postoperative nausea and vomiting (PONV) is a common and significant complication in otologic procedures. Due to middle ear stimulation, prolonged microsurgical duration, and inner ear irrigation, the incidence of PONV can reach 50 to 70 percent without appropriate prophylaxis. This condition contributes to extended recovery times, higher rates of unplanned admissions, and reduced patient satisfaction. The following guide outlines a comprehensive strategy, including pharmacologic options, fluid targets, and adjunctive therapies, to minimize PONV in ear surgery patients.
Effective prevention begins with risk assessment. Four factors are commonly used to determine a patient’s baseline PONV risk: female gender, non-smoking status, prior history of PONV or motion sickness, and anticipated postoperative opioid use. Each factor scores one point.
A multimodal pharmacologic approach is the most effective way to prevent and manage PONV. Recommended agents include:
Triple therapy is recommended for high-risk patients, typically combining dexamethasone, ondansetron, and scopolamine.
Anesthetic adjustments significantly impact PONV rates. The use of total intravenous anesthesia (TIVA) with propofol has been shown to reduce PONV incidence by approximately 20 percent compared to volatile agents. Nitrous oxide should be limited or avoided, as it can cause middle ear distention and vertigo. Opioid-sparing regimens using agents such as intravenous acetaminophen, ketorolac, and dexmedetomidine infusions are preferred.
Inadequate hydration increases the likelihood of PONV. Maintain crystalloid infusion rates at approximately 3 mL per kg per hour to support hemodynamic stability. Avoid hypotension with mean arterial pressures below 60 mm Hg, which can trigger vestibular-related nausea. When vasopressors are required, phenylephrine is preferred due to its limited effect on heart rate.
Several non-drug methods are effective adjuncts to pharmacologic management:
In cases where prophylaxis fails, a structured rescue plan should be implemented:
Documentation should reflect failure of two distinct drug classes before repeating serotonin antagonists.
Track PONV-related outcomes to ensure protocol effectiveness and maintain quality benchmarks. Key metrics include:
Routine audits and cross-disciplinary feedback help maintain high standards of care.
A comprehensive, evidence-based strategy for reducing PONV in ear surgery includes accurate risk stratification, strategic use of multiple anti-emetic drug classes, adjustments to anesthetic techniques, fluid management, and supportive non-pharmacologic measures. By implementing these practices, facilities can significantly reduce nausea-related complications, enhance patient recovery, and improve overall satisfaction.
For facilities aiming to implement standardized anti-emetic protocols or staff education, Advanced Anesthesia Services offers turnkey solutions tailored to ENT procedures.