Les stratégies thérapeutiques les plus efficaces pour faire face au nausées

Effective therapeutic strategies for managing nausea and vomiting during the perioperative period involve a multifaceted, risk-adapted, and multimodal approach integrating pharmacologic, anesthetic, and non-pharmacologic interventions.

Firstly, accurate preoperative risk assessment using validated tools such as the Apfel score is essential to stratify patients into low, moderate, or high risk for postoperative nausea and vomiting (PONV). Key patient-related risk factors include female sex, younger age, non-smoking status, and history of motion sickness or prior PONV. Surgical factors (e.g., laparoscopic, gynecologic, breast, and otolaryngologic procedures) and anesthetic factors (use of volatile anesthetics, nitrous oxide, and perioperative opioids) further elevate risk and guide prophylaxis intensity Dombrower et al. 2026 Dombrower et al. 2026.

Pharmacologic prophylaxis is the cornerstone of PONV management, especially in moderate to high-risk patients, where multimodal therapy targeting complementary emetic pathways significantly improves efficacy over single agents SmPC Setofilm,SmPC SETOFILM,SmPC Ondansetron,SmPC Droperidol,Dombrower et al. 2026 Kranke & Eberhart 2011Elvir-Lazo et al. 2020Dombrower et al. 2026. Common pharmacologic agents include:

• 5-HT3 receptor antagonists such as ondansetron, which have demonstrated proven efficacy and favourable safety profiles and are typically given near the end of surgery SmPC Ondansetron,Dombrower et al. 2026 Cao et al. 2017Dombrower et al. 2026.
• Corticosteroids like dexamethasone, usually administered at anesthetic induction, enhance efficacy when combined with other antiemetics Dombrower et al. 2026 Dombrower et al. 2026.
• Neurokinin-1 (NK1) receptor antagonists (e.g., aprepitant) have shown additional benefit in high-risk or highly emetogenic surgical settings SmPC Setofilm,Dombrower et al. 2026 Dombrower et al. 2026.
• Dopamine antagonists such as droperidol can be used as adjuncts or rescue therapy, although they carry considerations related to QT interval prolongation and other side effects SmPC Droperidol,Dombrower et al. 2026 Dombrower et al. 2026.

Combination therapy with agents acting on different receptors (e.g., 5-HT3 antagonist plus dexamethasone, or adding NK1 antagonists in higher-risk patients) offers additive protection and reduces the incidence and severity of PONV SmPC Setofilm,SmPC Droperidol,Dombrower et al. 2026 Cao et al. 2017Dombrower et al. 2026. Optimizing the timing of administration according to pharmacodynamics (corticosteroids at induction; 5-HT3 antagonists near surgery end) improves outcomes Dombrower et al. 2026 Dombrower et al. 2026.

Anesthetic technique significantly influences PONV risk, with volume inhalational anesthetics and nitrous oxide increasing risk, while total intravenous anesthesia (TIVA) with propofol reduces it. Regional anesthesia techniques, including neuraxial and peripheral nerve blocks, reduce opioid requirements and therefore lessen PONV risk NICE NG180,Dombrower et al. 2026 Dombrower et al. 2026. Opioid-sparing multimodal analgesia incorporating acetaminophen, NSAIDs, gabapentinoids, and regional techniques is essential to minimize emetogenic opioid exposure NICE NG180,Dombrower et al. 2026 Dombrower et al. 2026.

Non-pharmacologic strategies serve as valuable adjuncts within perioperative care pathways and include:

• Optimized perioperative fluid management using goal-directed therapy to maintain euvolemia, which reduces nausea risk Dombrower et al. 2026,Breaux et al. 2026 Dombrower et al. 2026Breaux et al. 2026.
• Early oral intake and mobilization after surgery, supporting gastrointestinal motility and reducing nausea Dombrower et al. 2026 Dombrower et al. 2026.
• Acupressure or acupuncture at the P6 (Neiguan) point, which has shown modest but consistent antiemetic effects Dombrower et al. 2026 Dombrower et al. 2026.
• Patient education and expectation management to reduce symptom reporting and anxiety, thereby diminishing PONV burden Dombrower et al. 2026 Dombrower et al. 2026.

Additionally, perioperative intravenous dextrose infusion has emerged as a promising non-pharmacologic adjunct that may reduce postoperative nausea and the requirement for rescue antiemetics by maintaining normoglycemia, suppressing ketogenesis, and stabilizing autonomic and metabolic stress responses related to fasting and surgical trauma. However, its effect on vomiting is inconsistent, and careful glucose and electrolyte monitoring is required to avoid hyperglycemia and osmotic diuresis, especially in patients with diabetes or insulin resistance Breaux et al. 2026 Breaux et al. 2026.

Close postoperative monitoring for breakthrough symptoms is important, with rescue antiemetic use guided by mechanism switching to avoid repetitive single-agent administration Dombrower et al. 2026 Dombrower et al. 2026. A continuous quality improvement approach employing protocolized pathways, checklists integrated into electronic health records, and multidisciplinary collaboration enhances adherence to best practices and reduces PONV incidence Stallings et al. 2026 Stallings et al. 2026.

In summary, the most effective management of nausea and vomiting during the perioperative period comprises:

• Individualized preoperative risk assessment to guide prophylaxis intensity.
• Multimodal pharmacologic prophylaxis combining agents acting on different emetic pathways.
• Optimization of anesthetic technique to minimize emetogenic agents and opioid exposure.
• Incorporation of non-pharmacologic interventions such as goal-directed fluid therapy, early mobilization, acupressure, patient education, and potentially intravenous dextrose infusion.
• Postoperative monitoring and rescue therapy within a structured multidisciplinary protocol.

This integrated approach embedded within Enhanced Recovery After Surgery protocols improves patient outcomes, satisfaction, and reduces healthcare costs associated with PONV Dombrower et al. 2026,Stallings et al. 2026 Dombrower et al. 2026Stallings et al. 2026.