Apfel Score–Guided Management of Postoperative Nausea and Vomiting
Risk Stratification and Baseline Incidence
First‑Line Antiemetic Drug Classes (American Society of Anesthesiologists)
Non‑Pharmacologic Strategies to Lower Baseline Risk
Integrated Prophylactic Approach (American Society of Anesthesiologists)
Postoperative Nausea and Vomiting Risk Assessment and Management
Introduction to Apfel Score
- The Apfel score is a simplified 4-factor risk assessment tool that predicts postoperative nausea and vomiting (PONV) by assigning one point each for: female gender, non-smoking status, history of PONV or motion sickness, and postoperative opioid use, as recommended by the ERAS Society 4, 5
Risk Stratification and Prophylaxis
- For patients with Apfel score ≥2 (two or more risk factors), prophylactic antiemetic therapy is strongly recommended, with the administration of a combination of two antiemetics from different drug classes for moderate risk and 2-3 antiemetics for high risk 6, 7
- The ERAS Society guidelines recommend selecting from six drug classes for first-line antiemetic therapy, including 5-HT3 receptor antagonists, corticosteroids, dopamine (D2) antagonists, neurokinin-1 receptor antagonists, antihistamines, and anticholinergics 4, 5, 8
Additional Risk Reduction Strategies
- Use of total intravenous anesthesia (TIVA) with propofol instead of volatile anesthetic gases reduces PONV risk 4, 5, 6
- Avoidance of nitrous oxide reduces PONV risk 4, 5
- Implementation of opioid-sparing multimodal analgesia reduces PONV risk 4, 5, 6
- Ensuring adequate hydration with mildly positive fluid balance reduces PONV risk 9
- Consideration of carbohydrate loading preoperatively reduces PONV risk 4, 9