Postoperative Nausea and Vomiting (PONV) Risk & Management
Calculate Apfel score for postoperative nausea and vomiting (PONV) risk. Stratify prophylaxis need and select multi-mechanism antiemetic agents based on risk category.
Based on: Apfel 1999 · SAMBA 2020
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Overview
Apfel simplified risk score for postoperative nausea and vomiting (PONV). Four independent predictors classify patients into low, moderate, or high risk and guide the number of prophylactic antiemetic agents and anesthetic technique.
Evidence Summary
The Apfel simplified risk score was derived and validated by Apfel et al. (1999) in a large multicenter trial. Female sex is the strongest predictor, followed by history of PONV or motion sickness, non-smoking status, and planned postoperative opioids — each contributing equally (1 point). The score reliably stratifies patients into four incidence bands.
| Score | PONV incidence | Risk | Recommended approach |
|---|---|---|---|
| 0 | ≈10% | Low | No routine prophylaxis |
| 1 | ≈21% | Low | Consider single agent |
| 2 | ≈39% | Moderate | Two-drug combination |
| 3 | ≈61% | High | Multimodal ≥2 classes + consider TIVA |
| 4 | ≈79% | High | Multimodal ≥2 classes + TIVA |
SAMBA 2020 guidelines recommend a multimodal approach for moderate-to-high risk patients, combining agents from different mechanism classes (5-HT3 antagonists, corticosteroids, NK1 antagonists, dopamine antagonists). For rescue therapy, guidelines consistently recommend using a drug from a different class than what was used for prophylaxis.