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Post-Op Pain & PONV Playbook
Multimodal pain ladder, opioid equivalents, PONV risk scoring and the rescue order that actually works.
Free · print it · share it · no gatekeeping
Multimodal first
- Acetaminophen
- 1 g IV/PO q6h (max 4 g/day, less if hepatic disease)
- NSAID
- Ketorolac 15–30 mg IV q6h · avoid in renal impairment, bleeding, some ortho/plastics
- Gabapentinoid
- Per protocol · watch sedation in the elderly
- Regional
- Ask about the block before you chase pain with opioids
- Non-pharm
- Ice, position, reassurance, bladder scan — a full bladder mimics agony
Opioid rough equivalents (IV)
- Fentanyl 100 mcg
- ≈ morphine 10 mg · onset 1–2 min, short
- Hydromorphone 1.5 mg
- ≈ morphine 10 mg · onset 5 min, potent — go slow
- Morphine 10 mg
- Reference · histamine release, renal metabolites accumulate
- Reversal
- Naloxone 0.04–0.4 mg IV, titrate — don't erase all analgesia
PONV — Apfel risk score (1 point each)
- Risk factors
- Female · non-smoker · history of PONV/motion sickness · post-op opioids
- Risk
- 0 = ~10% · 1 = ~20% · 2 = ~40% · 3 = ~60% · 4 = ~80%
- Strategy
- Give one prophylactic agent per risk point, from different classes
PONV rescue (use a DIFFERENT class than prophylaxis)
- Ondansetron
- 4 mg IV · 5-HT3 · watch QT
- Dexamethasone
- 4–8 mg IV · give early, works late
- Promethazine
- 6.25–12.5 mg IV · sedating, tissue-toxic — dilute well
- Scopolamine
- Patch · dry mouth, confusion in the elderly
- Haloperidol/droperidol
- Low dose per protocol · QT monitoring
- Non-drug
- Oxygen, hydration, avoid sudden movement, aromatherapy per policy
Baddie pearls 👑
- ✦Restlessness in PACU is hypoxia until proven otherwise — check the sat before you push more opioid.
- ✦Repeating the same failed antiemetic is the #1 PONV mistake. Change classes.
- ✦Reassess and document 15–30 minutes after every dose. That's the part audits look for.
Educational reference only. Always follow your facility's current policies, protocols, and provider orders.
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