Utilization Review Checklist
Antiemetics for Peri-operative Nausea and Vomiting
Derived from the ACOEM Antiemetics Guideline, edition 27 March 2020, as adopted into the California MTUS 26 October 2020. ICD-10 R11.0, R11.2, T88.7XXA, Z98.890.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
Procedures — the guideline treats each separately
Antiemetics for peri-operative nausea and vomiting, or severe pain causing nausea and vomiting
Moderately Recommended.
Strength of Evidence — Moderately Recommended, Evidence (B) · confidence high
Indications
Any one of the following
Pre-, peri- or post-operative nausea and emesis, present or anticipated
“Indications: Pre-, peri- and post-operative nausea and emesis.” — p. 4
OR
Prophylactic use pre-operatively or at the end of the procedure where emesis is anticipated and would significantly affect the procedure or wound
“Often used prophylactically either pre-operatively or at the end of the operative procedure when emesis is potentially anticipated and/or has significant impacts on the type of surgical procedure/wound.” — p. 4
OR
Severe pain without surgery associated with nausea, warranting treatment
“In infrequent cases, severe pain without surgery may be associated with nausea and warrant treatment.” — p. 4
Contraindications and Cautions
Required
Adverse effects of the chosen agent have been considered — drowsiness, dry mouth, urinary retention, blurred vision, sedation, tremor
“Adverse effects vary based on type of medication. Common adverse effects include drowsiness, dry mouth, urinary retention, blurred vision, sedation, tremor.” — p. 4
Prior Treatment(informational — not scored)
Required
The route is stated; if rectal, the common routes and combinations tried first are recorded
“The rectal route is used typically as a tertiary strategy after common routes and/or combinations of medications have failed, although supportive quality studies were not found for rectal (PR) administration.” — p. 4
Dose, Duration and Discontinuation
Required
Dose and route are per manufacturer recommendation
“Per manufacturer recommendation.” — p. 4
Supported, including PROPHYLACTIC use pre-operatively or at the close of the operation where emesis is anticipated. Prophylaxis being explicitly covered is worth knowing: a request framed as prevention rather than treatment is still within the recommendation.