术后恶心呕吐：当前概念、管理策略与未来展望。

文献信息

中文摘要

术后恶心呕吐（PONV）仍然是麻醉和手术后最常见且最令人痛苦的不良事件之一，对患者舒适度、恢复质量、出院准备度和医疗资源使用具有重要影响。尽管麻醉技术、止吐药理学和加速康复路径的进展改善了围手术期护理，但由于其多因素病理生理机制和个体易感性的差异，PONV仍频繁发生。本叙述性综述提供了PONV当前概念的临床导向概述，包括流行病学、临床负担、神经化学机制、危险因素、预测模型、基线风险降低、药物预防、补救治疗、出院后护理和未来展望。PONV源于中枢和外周催吐通路之间复杂的相互作用，包括胃肠道迷走传入、化学感受器触发区、前庭输入、高级皮质和边缘系统调制，以及多种神经递质系统，如5-羟色胺、多巴胺、组胺、乙酰胆碱、P物质和阿片介导的信号传导。结构化风险评估，特别是使用Apfel评分等简化预测工具，对于指导个体化预防仍然至关重要。预防策略应结合减少可改变的围手术期危险因素与适当的多模式止吐治疗。关键干预措施包括在合适时尽量减少挥发性麻醉药和氧化亚氮的暴露、使用阿片节约型镇痛、优化补液和禁食实践，以及在适当情况下整合区域或椎管内技术。药物管理依赖于靶向不同受体系统的药物，包括5-HT3受体拮抗剂、多巴胺受体拮抗剂、神经激肽-1受体拮抗剂、糖皮质激素、抗胆碱能药和抗组胺药。未来研究应提高预测准确性、阐明最佳预防组合、加强指南实施、评估出院后症状，并探索人工智能辅助的个体化预防。全面、基于风险且以患者为中心的方法仍然是减轻PONV负担的核心。

英文摘要

Postoperative nausea and vomiting (PONV) remains one of the most common and distressing adverse events after anesthesia and surgery, with important effects on patient comfort, recovery quality, discharge readiness, and healthcare resource use. Although advances in anesthetic techniques, antiemetic pharmacology, and enhanced recovery pathways have improved perioperative care, PONV continues to occur frequently because of its multifactorial pathophysiology and variable individual susceptibility. This narrative review provides a clinically oriented overview of current concepts in PONV, including epidemiology, clinical burden, neurochemical mechanisms, risk factors, prediction models, baseline risk reduction, pharmacological prophylaxis, rescue treatment, postdischarge care and future perspectives. PONV results from complex interactions among central and peripheral emetic pathways, including gastrointestinal vagal afferents, the chemoreceptor trigger zone, vestibular input, higher cortical and limbic modulation, and multiple neurotransmitter systems such as serotonin, dopamine, histamine, acetylcholine, substance P, and opioid-mediated signaling. Structured risk assessment, particularly using simplified prediction tools such as the Apfel score, remains essential for guiding individualized prophylaxis. Preventive strategies should combine reduction of modifiable perioperative risk factors with appropriate multimodal antiemetic therapy. Key interventions include minimizing exposure to volatile anesthetics and nitrous oxide when suitable, using opioid-sparing analgesia, optimizing hydration and fasting practices, and integrating regional or neuraxial techniques when appropriate. Pharmacological management relies on agents targeting different receptor systems, including 5-HT3 receptor antagonists, dopamine receptor antagonists, neurokinin-1 receptor antagonists, glucocorticoids, anticholinergics, and antihistamines. Future research should improve prediction accuracy, clarify optimal prophylactic combinations, strengthen guideline implementation, evaluate postdischarge symptoms, and explore artificial intelligence-assisted individualized prevention. A comprehensive, risk-based, and patient-centered approach remains central to reducing the burden of PONV.