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4/30/26 Anesthesiology Grand Rounds -1991-2026: (i) Meaningful Prophylaxis Against the PoNV Big Little Problem, and (ii) Meaningful Prevention of Usual Opioid Exposure during Routine Anesthesia Care

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EVALUATION

CERTIFICATE

INTRODUCTION

Credit Hours: 1.00

Target Audience:

Anesthesiologists and anesthesiologists-in-training and other anesthesia professionals, nurse anesthetists and anesthesia assistants.

Educational Objectives:

Upon completion of this activity, participants should be able to:

  • Evaluate paradigm-shifting postoperative nausea and vomiting (PONV) developments since ~2010 and apply multimodal prophylaxis strategies (e.g., 5-drug antiemetic protocols with 3-drug postoperative boosters) to achieve target PONV prevention rates of 95% on POD#0 and 90% on POD#1+.
  • Explain the clinical rationale for incorporating intrathecal morphine and spinal magnesium in conjunction with multimodal antiemetic regimens and assess their role in reducing reliance on short-term, high abuse-liability opioids.
  • Implement a three-analgesic, non-opioid multimodal regimen (when fully administered without missed doses) to optimize postoperative pain control and reduce the use of high abuse-liability opioids, including intraoperative avoidance strategies.
  • Analyze the likelihood and clinical implications of rebound PONV associated with routine ondansetron use and select evidence-based alternatives, such as palonosetron, to minimize breakthrough and rebound symptoms.
  • Balance the symptomatic trade-offs of intrathecal morphine plus magnesium (ITM+Mg) use by managing associated adverse effects (e.g., pruritus) with targeted treatment strategies and propose research-informed approaches to identify lower abuse-liability opioid alternatives that reduce reliance on ITM+Mg.

Suggested Additional Reading:

  1. Williams BA, Choragudi R, Schumacher CA, Garbelotti KE, Ezaru CS, Boudreaux-Kelly MY, et al. Upgrading intrathecal morphine for postoperative pain mitigation in abdominal surgery: an exploratory multiple regression analysis of observational data addressing co-administered spinal magnesium sulfate, en route to both enhanced systemic opioid sparing and opioid avoidance. Front Anesthesiol. (2025) 4:1592643. doi: 10.3389/fanes.2025.1592643
  2. Williams BA, Hall DE, Dalessandro C, Garbelotti KE, Ludden JM. Patient-centered intrathecal morphine dose-response in major abdominal surgeries when augmented by innovative five-drug antiemetic prophylaxis. Front Anesthesiol. (2025) 4:1521409. doi: 10.3389/fanes.2025.1521409
  3. Apfel CC, Philip BK, Cakmakkaya OS, Shilling A, Shi YY, Leslie JB, et al. Who is at risk for postdischarge nausea and vomiting after ambulatory surgery? Anesthesiology. (2012) 117: 475–86. doi: 10.1097/ALN.0b013e318267ef31
  4. Apfel CC, Jukar-Rao S. Is palonosetron also effective for opioid-induced and post-discharge nausea and vomiting? Br J Anaesth. (2012) 108: 371–3. doi: 10.1093/bja/aer516
  5. Williams BA, Schumacher CA, Choragudi R, Garbelotti KE, Ludden JM, Hall DE. historical perspectives supporting the ambitious anesthetist aiming for zero nausea/vomiting: should one trust every consensus statement every time? Front Anesthesiol. (2025) 3(1525030):1–7. doi: 10.3389/fanes.2024.1525030

Authors:
Brian A. Williams, MD, MBA, FASRA — Professor of Anesthesiology and Perioperative Medicine, and Clinical and Translational Science Institute (CTSI), University of Pittsburgh School of Medicine; VA Pittsburgh Healthcare System - Acute Pain Medicine (9/2010 – 7/2025)
No relationships with industry relevant to the content of this educational activity have been disclosed.
No other members of the planning committee, speakers, presenters, authors, content reviewers and/or anyone else in a position to control the content of this education activity have relevant financial relationships with any companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

The University of Pittsburgh School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. The University of Pittsburgh School of Medicine designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Each physician should only claim credit commensurate with the extent of their participation in the activity.

Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

The University of Pittsburgh is an affirmative action, equal opportunity institution.