Apfel PONV Score

CRNA Study Suite · Postoperative Nausea/Vomiting Risk
All Calculators Apfel
Risk Factors (1 pt each)
Apfel Score
0
of 4
Risk Interpretation
ScorePONV Risk (24h)Prophylaxis
0~10%None or single agent
1~20%1 agent (5-HT3 or dex)
2~40%2 agents
3~60%3 agents; consider TIVA
4~80%Multimodal + TIVA; avoid N₂O/volatiles
Common Prophylactic Agents
• Ondansetron 4 mg IV (end of surgery)
• Dexamethasone 4-8 mg IV (on induction)
• Scopolamine patch 1.5 mg TD (preop)
• Haloperidol 0.5-1 mg IV (induction)
• Aprepitant 40 mg PO (preop) — NK1 antagonist
• TIVA with propofol — reduces PONV by ~25%
References

Apfel, C. C., Läärä, E., Koivuranta, M., Greim, C. A., & Roewer, N. (1999). A simplified risk score for predicting postoperative nausea and vomiting. Anesthesiology, 91(3), 693-700. (Original Apfel score publication — widely cited in CRNA textbooks including Bordi, 2023; also in Stoelting's Anesthesia and Co-existing Disease.)

How this works

The four risk factors

The Apfel simplified PONV risk score uses four independent risk factors: female gender, nonsmoking status, history of PONV or motion sickness, and planned postoperative opioid use (Odom-Forren & Brady, 2023, p. 1287). Incidence rises with each: about 10 to 20% with one factor, 40% with two, 60% with three, and 80% with four (Odom-Forren & Brady, 2023, p. 1287).

Prophylaxis implication

Patients with one to two factors should receive two antiemetics from different classes; more than two factors warrants three to four agents, per the SAMBA consensus guidelines (Odom-Forren & Brady, 2023, pp. 1287-1288). Supporting strategies include minimizing volatiles and nitrous oxide, opioid sparing multimodal analgesia, and propofol based TIVA or regional technique (Odom-Forren & Brady, 2023, p. 1287).

References

Odom-Forren, J., & Brady, J. M. (2023). Postanesthesia recovery. In Elisha, Heiner, & Nagelhout (Eds.), Nurse anesthesia (7th ed., pp. 1272-1292). Elsevier.