Adult PONV: assess risk before surgery
Adults only. Children need a paediatric vomiting pathway.
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AnesthesiologyManagement
Postoperative Nausea and Vomiting (PONV) Management
Postoperative Nausea and Vomiting (PONV) Management: Adult PONV: assess risk before surgery → Count Apfel risk factors (adults) → Before choosing drugs:...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Count Apfel risk factors (adults)
One point for each factor present
- Female sex
- Non-smoker
- History of PONV or motion sickness
- Opioids expected after surgery
- Risk with 0, 1, 2, 3, 4 factors: about 10%, 20%, 40%, 60%, 80%
- Risk is also higher with younger age and some surgery types (for example laparoscopic, bariatric, gynaecological, cholecystectomy)
03Warning Before choosing drugs: Parkinson's, Lewy body dementia, long QT, apomorphine
Also: no droperidol in phaeochromocytoma. Dexamethasone causes a small, short rise in blood glucose in diabetes; check glucose.
- Parkinson's disease or Lewy body dementia: do not give droperidol, haloperidol, prochlorperazine, metoclopramide or promethazine. Use dexamethasone, ondansetron (not with apomorphine), aprepitant or propofol TIVA.
- Long QT, QTc above 440 ms (male) or 450 ms (female), QT-prolonging drugs, low K or Mg, or bradycardia: do not give droperidol, haloperidol or prochlorperazine. Congenital long QT: avoid ondansetron. Use dexamethasone, aprepitant, propofol TIVA; correct K and Mg.
- Taking apomorphine: do not give ondansetron or any other 5-HT3 antagonist (profound hypotension and loss of consciousness).
04Action Reduce baseline risk (all patients)
Anaesthetic and analgesic choices
- Opioid-sparing multimodal analgesia (paracetamol; NSAID if suitable; caution in bowel anastomosis)
- Regional or local anaesthesia when suitable
- Propofol TIVA instead of volatile agents
- Avoid nitrous oxide for maintenance
- Sugammadex rather than neostigmine for reversal
- Adequate hydration; avoid hypotension
05Action Choose number of prophylactic agents by risk (adults)
Agents from different classes, plus risk reduction for all
- 0 factors (about 10%): consider 2 agents; give them if vomiting would be dangerous (for example raised intracranial pressure, wired jaw)
- 1-2 factors: give 2 agents
- 3-4 factors: give 3-4 agents and maximise risk reduction; evidence for 3 or more agents is limited
- Prescribe a rescue antiemetic from a different class for every patient
06Action Prophylaxis drugs: adult doses
Usual first pair: dexamethasone plus ondansetron. Add others from different classes.
- Dexamethasone 4-8 mg IV at induction
- Ondansetron 4 mg IV at end of surgery
- Droperidol 0.625 mg IV at end of surgery (not with QT risk, Parkinson's or phaeochromocytoma)
- Aprepitant 40-80 mg PO at induction. It can stop hormonal contraception working for 28 days: advise a backup method.
- Haloperidol 0.5 to less than 2 mg IM; IV only with continuous ECG monitoring (not with QT risk or Parkinson's)
- Promethazine 6.25 mg (deep IM preferred; not in Parkinson's)
- Propofol TIVA or acupoint (P6) stimulation can count as one intervention
07Decision Free of nausea and vomiting after surgery?
Assess in recovery and on the ward
- If Yes
08Action No PONV, or settled after rescue: plan discharge
Discharge when local recovery or day-surgery criteria are met
- Post-discharge risk factors: female, age under 50, history of PONV, opioids in recovery, nausea in recovery
- High post-discharge risk: give a long-acting antiemetic before discharge, or supply ondansetron ODT to take at home
- Tell the patient when to seek care (persistent vomiting, cannot keep fluids down)
09Outcome PONV managed
Patient comfortable; no nausea or vomiting
If No10Action PONV present: rescue with a different drug class
First look for a cause: hypotension, hypoxia, excess opioid, blood in the pharynx, bowel obstruction. Check BP and SpO2. Adult doses.
- No prophylaxis given: ondansetron 4 mg IV
- Ondansetron already given: droperidol 0.625-1.25 mg IV (no QT risk, no Parkinson's) or promethazine 6.25 mg (not in Parkinson's)
- Promethazine: deep IM preferred. IV only into a free-running line: it can cause severe tissue injury.
- Another 5-HT3 antagonist adds no benefit after failed ondansetron
- Do not repeat a drug class within 6 h. After 6 h, a 5-HT3 antagonist or droperidol may be repeated if there is no alternative.
- Do not re-dose aprepitant or palonosetron. A hyoscine patch acts too slowly for rescue.
- Propofol 20-40 mg IV, monitored recovery area only; the effect is brief
11Decision Settled after rescue?
Yes: plan discharge (step above). No: reassess and escalate.
- If Yes
- Path rejoins step 08Shared downstream outcome
If No12Action Not settled after rescue: reassess and escalate
Adult doses
- Reassess for a surgical or medical cause (for example ileus, obstruction, bleeding, excess opioid)
- Check electrolytes and glucose
- Add a drug from a class not yet used; a combination of classes may work better than one drug
- Prochlorperazine 12.5 mg by deep IM injection (not IV); not with Parkinson's disease or QT risk
- Senior review; continue treatment on the ward while it persists
13Outcome PONV not yet settled: ward care with senior review
Keep treating the cause and review fluids, electrolytes and drugs
Guideline Source
Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: Executive Summary
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Children need a paediatric vomiting pathway (different risk score and weight-based doses).
- Doses are adult doses from the 2025 consensus. In Australia, IV amisulpride and hyoscine patches are not on the ARTG; check the local formulary.
- Does not cover chemotherapy-induced nausea or nausea in pregnancy.
- The consensus gives no specific advice for pregnant patients having non-obstetric surgery.
- Check drug interactions and allergies before each drug.
Contraindicated Populations
pediatric
Applicable Regions
USEUAUglobal
AU: Transdermal hyoscine and IV amisulpride are not on the ARTG. Prochlorperazine injection is for deep IM use only (12.5 mg adult). Droperidol is registered (2.5 mg/mL).
Global: Based on the Fifth Consensus Guidelines for PONV (Gan et al, Anesth Analg 2025).
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Postoperative Nausea and Vomiting (PONV) Management?
The Postoperative Nausea and Vomiting (PONV) Management is a management clinical algorithm for Anesthesiology. It provides a structured decision tree to guide clinical decision-making, based on Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: Executive Summary.
What guideline is the Postoperative Nausea and Vomiting (PONV) Management based on?
This algorithm is based on Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: Executive Summary (DOI: 10.1213/ANE.0000000000007816).
What are the limitations of the Postoperative Nausea and Vomiting (PONV) Management?
Known limitations include: Adults only. Children need a paediatric vomiting pathway (different risk score and weight-based doses).; Doses are adult doses from the 2025 consensus. In Australia, IV amisulpride and hyoscine patches are not on the ARTG; check the local formulary.; Does not cover chemotherapy-induced nausea or nausea in pregnancy.; The consensus gives no specific advice for pregnant patients having non-obstetric surgery.; Check drug interactions and allergies before each drug.. Individual patient factors may require deviation from these recommendations.
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