PONV remains one of the most common complications of general anesthesia, affecting 30% of all surgical patients and up to 80% of high-risk patients. The Fourth Consensus Guidelines for Management of PONV recommend a risk-stratified, multimodal approach combining pharmacologic and non-pharmacologic strategies to minimize this significant source of patient dissatisfaction.
Apfel risk factors: female sex, non-smoking status, history of PONV/motion sickness, postoperative opioids
Multimodal prophylaxis recommended for ≥2 risk factors; each intervention reduces risk ~25%
First-line agents: ondansetron 4 mg, dexamethasone 4–8 mg, droperidol 0.625–1.25 mg
TIVA with propofol reduces PONV risk compared to volatile-based anesthesia
Rescue antiemetics should be from a different class than prophylactic agents used
For patients with ≥3 Apfel risk factors, combine at least 3 prophylactic interventions: consider TIVA (propofol-based, avoids volatiles), ondansetron at end of case, dexamethasone at induction, and minimize opioids with multimodal analgesia.
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