A 2021 publication provides an Australian perspective on the Fourth Consensus Guidelines for the management of postoperative nausea and vomiting (PONV). The guidelines emphasize the importance of conducting a baseline assessment of patient-specific PONV risk for all patients. This assessment should consider the patient's risk of vomiting postoperatively, especially in cases with elevated intracranial pressure. The guidelines integrate a range of risk factors, including patient-specific and anesthetic-related elements. For adults, patient-specific risk factors supported by level B1 evidence include female gender, a history of PONV or motion sickness, non-smoking status, and being younger than 50 years. In children, risk factors include being over three years old, a history of PONV or motion sickness, and a family history of PONV. Anesthetic and surgical risk factors for PONV in adults include the use of general anesthesia over regional anesthesia, volatile anesthetics, nitrous oxide exposure for more than an hour, anesthesia duration, postoperative opioid use, and specific types of surgeries like cholecystectomy and laparoscopic gynecological procedures. In children, factors such as strabismus surgery, adenotonsillectomy, otoplasty, surgeries longer than 30 minutes, volatile anesthetics, anticholinesterases, and long-acting opioids contribute to PONV risk. [1]
Across major guidelines, PONV risk is driven by both surgical and patient-related factors, with substantial overlap in identified predictors. Guidelines identify bariatric surgery as having the highest PONV risk, with other consistently high-risk procedures including laparoscopic cholecystectomy, urologic surgery, knee arthroplasty, and breast, gynecologic, and obstetric surgeries. The 2023 Enhanced Recovery After Colon and Rectal Surgery guidelines (ASCRS/SAGES) further emphasize laparoscopic approaches, prolonged operative time, use of volatile anesthetics, and perioperative opioid exposure as procedure-related contributors. The 2019 guideline on PONV after craniotomy highlights neurosurgical procedures as a distinct high-risk population, where vomiting has added clinical consequences. [2], [3], [4]
Patient characteristics most strongly associated with increased PONV risk are consistent across guidelines and validated risk models, including female sex, younger age, history of PONV or motion sickness, nonsmoking status, and perioperative opioid use. Additional evidence notes that laparoscopic surgery and volatile anesthesia increase risk, whereas higher BMI, higher hemoglobin/hematocrit, and ASA class III status were paradoxically associated with lower PONV incidence in retrospective analyses. Novel laboratory markers (elevated neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios) and intraoperative factors such as hypotension have also been associated with increased risk, while goal-directed hemodynamic management may be protective. For postdischarge nausea and vomiting, a simplified score incorporating female sex, age <50 years, prior PONV, opioid use in the PACU, and nausea in the PACU demonstrates a graded increase in risk with accumulating factors. [2], [3], [4]
Review articles are concordant with guideline recommendations and further refine the relative importance of individual risk factors. A 2012 systematic review analyzed risk factors for PONV by synthesizing data from 22 studies involving a total of 95,154 patients. The analysis incorporated diverse studies that each enrolled over 500 patients, ensuring robust data reliability. Odds ratios (ORs) from individual studies were pooled to provide accurate overall point estimates for each potential risk factor. The results highlighted that the most significant patient-specific predictors of PONV included female gender with an OR of 2.57, a history of PONV or motion sickness (OR 2.09), non-smoking status (OR 1.82), and younger age, with an OR decrease of 0.88 per decade. Among anesthesia-related factors, the use of volatile anesthetics emerged as a substantial predictor (OR 1.82), alongside prolonged duration of anesthesia (OR 1.46 per hour), postoperative opioid use (OR 1.39), and nitrous oxide (OR 1.45). Among the 13 surgical categories evaluated, only three achieved statistical significance as predictors of PONV. Cholecystectomy emerged as the most significant predictor with an OR of 1.90, indicating a strong association with PONV. This was followed by laparoscopic procedures, which had an OR of 1.37, and gynaecological surgery, with an OR of 1.24. The other surgical types analyzed—ENT (ear, nose, and throat), ophthalmologic, thyroid, abdominal, orthopaedic, neurological, plastic, and head and neck surgery—did not reach statistical significance as predictors of PONV. The analysis of funnel plots indicated potential publication bias towards positive results in surgical categories, while patient-specific and anesthesia-related factors showed more consistent evidence, underscoring their utility in predicting PONV. A more recent narrative review contextualizes these findings mechanistically, emphasizing that while patient and surgical factors are largely nonmodifiable, anesthetic and medication-related exposures represent key opportunities for intervention. It supports the use of validated risk scores (e.g., Apfel and pediatric-specific tools) and a multimodal, risk-adapted prophylactic approach, confirming that structured assessment and modification of anesthetic techniques remain central to effective PONV prevention. [5], [6]
A 2024 cross-sectional study investigated the operation-specific risk of postoperative nausea by analyzing data from 152 German and Austrian hospitals collected between 2013 and 2022 (Table 2). The study included a substantial cohort of 78,231 patients and utilized data from the Quality Improvement in Postoperative Pain Treatment (QUIPS) registry to assess the risk associated with 72 different surgical procedures. The results revealed a significant variability in the adjusted absolute risk of nausea, ranging from 6.2% to 36.2%, depending on the type of surgical procedure. Laparoscopic bariatric operations exhibited the highest risk at 36.2%, whereas procedures like toe amputation displayed a substantially lower risk of 6.2%. The analysis highlighted that male sex, perioperative antiemetic prophylaxis, intraoperative regional anesthesia, and preoperative opioid medication for chronic pain were protective factors against postoperative nausea. Conversely, perioperative opioid use significantly increased the risk, with odds ratios up to 2.38. The findings underscore the necessity for clinicians to consider the specific type of surgical procedure when evaluating the risk of postoperative nausea, advocating for tailored antiemetic strategies based on the operation-specific risk profile. [7]
Across diverse retrospective and observational designs, these studies consistently reinforce that PONV risk is multifactorial, with patient sex, anesthetic exposure, surgical complexity, and perioperative management emerging as dominant contributors. Female sex, longer surgical or anesthesia duration, and higher BMI were repeatedly associated with increased PONV risk, while major or laparoscopic procedures further amplified risk in general surgical populations. Several studies underscored the importance of anesthetic technique, demonstrating lower PONV rates with propofol-based total intravenous anesthesia and higher risk with volatile agents, particularly desflurane, while opioid exposure remained a relevant perioperative factor. Adequacy of prophylaxis was a recurring theme, with insufficient or limited antiemetic use associated with higher early PONV, and combination antiemetic strategies and agents such as ondansetron and droperidol showing protective effects. Novel findings from large-scale and machine learning–based analyses highlighted intraoperative blood loss and fluid balance as important predictors, suggesting a potential hemodynamic or volume-related contribution to PONV risk. [8], [9], [10], [11]