Preoperative PONV Risk Assessment
Identify risk factors before surgery
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AnesthesiologyManagement
Postoperative Nausea and Vomiting (PONV) Management
Postoperative Nausea and Vomiting (PONV) Management: Preoperative PONV Risk Assessment → Apfel Simplified Risk Score → Risk Level? → Low Risk (0-1 facto...
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Action Apfel Simplified Risk Score
Count number of risk factors present
- 1. Female sex
- 2. Non-smoker
- 3. History of PONV or motion sickness
- 4. Postoperative opioids expected
- Risk of PONV:
- 0 factors: 10%
- 1 factor: 21%
- 2 factors: 39%
- 3 factors: 61%
- 4 factors: 79%
03Decision Risk Level?
Based on Apfel score and surgery type
04Action Low Risk (0-1 factors)
No routine prophylaxis needed
- Consider single agent for high-risk surgery
- Have rescue antiemetics available
- Optimize hydration
- Avoid unnecessary opioids
05Action Intraoperative Risk Reduction
Anesthetic technique modifications
- TIVA: reduces PONV vs volatile by ~25%
- Avoid nitrous oxide in high-risk patients
- Regional anesthesia when appropriate
- Multimodal analgesia (NSAIDs, acetaminophen, regional)
- Adequate hydration (20-30 mL/kg)
- Sugammadex > neostigmine for reversal
06Decision PONV in PACU?
Patient experiencing nausea or vomiting
07Action Rescue Treatment
Use DIFFERENT class than prophylaxis
- If no prophylaxis given:
- Ondansetron 4 mg IV
- If ondansetron given for prophylaxis:
- Promethazine 6.25-12.5 mg IV OR
- Droperidol 0.625 mg IV OR
- Dexamethasone 4-8 mg (if not given) OR
- Propofol 20 mg IV (rescue only)
- If multiple prophylaxis agents given:
- Use agent from different class
- Consider propofol 20 mg IV for rescue
08Action Refractory PONV
Not responding to rescue
- Ensure no surgical cause (ileus, bleeding)
- Prochlorperazine 10 mg IV/IM
- Promethazine 12.5-25 mg IV
- Consider acupuncture (P6 point)
- Consider NK1 antagonist if available
- Evaluate for electrolyte imbalance
09Outcome PONV Managed
Patient comfortable for discharge
- Path rejoins step 09Shared downstream outcome
10Action No PONV - Discharge Criteria Met
Standard PACU discharge
- Tolerating clear fluids
- No active nausea
- Prescribe PRN antiemetic for home if high-risk
- Patient education on when to seek care
- Path rejoins step 09Shared downstream outcome
11Action Moderate Risk (2 factors)
1-2 prophylactic interventions
- CHOOSE 1-2:
- Dexamethasone 4-8 mg IV at induction
- Ondansetron 4 mg IV at end of surgery
- Droperidol 0.625-1.25 mg IV
- PLUS reduce baseline risk:
- TIVA (propofol-based) if possible
- Minimize opioids
- Adequate hydration
- Path rejoins step 05Shared downstream outcome
12Action High Risk (3-4 factors)
Multimodal prophylaxis required
- COMBINATION THERAPY (≥2 agents from different classes):
- Dexamethasone 4-8 mg IV at induction
- PLUS Ondansetron 4 mg IV end of surgery
- PLUS consider: Droperidol 0.625 mg OR
- Scopolamine patch OR NK1 antagonist
- REDUCE BASELINE RISK:
- TIVA with propofol
- Avoid nitrous oxide
- Minimize neostigmine (use sugammadex)
- Multimodal analgesia (minimize opioids)
- Adequate IV fluids
- Path rejoins step 05Shared downstream outcome
Guideline Source
Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Individual drug availability may vary
- Pediatric dosing differs
- Does not address chemotherapy-induced nausea
- Drug interactions should be checked
Applicable Regions
USEUglobal
US: Based on ASA-endorsed Fourth Consensus Guidelines
Global: Endorsed by 23 professional societies
Version 1Next review: 2027-01-01
Next steps
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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 Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting.
What guideline is the Postoperative Nausea and Vomiting (PONV) Management based on?
This algorithm is based on Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting (DOI: 10.1213/ANE.0000000000004833).
What are the limitations of the Postoperative Nausea and Vomiting (PONV) Management?
Known limitations include: Individual drug availability may vary; Pediatric dosing differs; Does not address chemotherapy-induced nausea; Drug interactions should be checked. Individual patient factors may require deviation from these recommendations.
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