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anesthesia.ponv-postop-nausea-vomiting.core.v1PRODUCTION
anesthesia.ponv-postop-nausea-vomiting.core.v1

Postoperative Nausea and Vomiting

general_internal_medicineacuteadultpediatric
Hard-required inputs
0 / 7
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm PONV scope — risk-stratify pre-induction, deliver multimodal prophylaxis matched to Apfel/Eberhart score, rescue with different drug class if breakthrough (SAMBA 2020)

Inputs
1
Actions
0
Advance rule
Set
Advance when

risk assessment initiated

Patient inputs (9)

Children >=3 yrs receive different prophylaxis dosing; pediatric POV scoring uses Eberhart score, not Apfel (SAMBA 2020)

Laparoscopic, gynecologic, ENT, breast, ophtho/strabismus = high-emetogenic (SAMBA 2020)

Droperidol black-box; ondansetron QT effect cumulative; baseline QT informs choice (SAMBA 2020)

Female sex = 1 Apfel point (Apfel 1999)

Non-smoker = 1 Apfel point (Apfel 1999)

Prior PONV or motion sickness = 1 Apfel point (Apfel 1999)

Postoperative opioids = 1 Apfel point (Apfel 1999)

Avoid dopamine antagonists (metoclopramide, droperidol, haloperidol, promethazine) in Parkinsons (SAMBA 2020)

Rescue threshold = patient distress; rescue with class different from prophylaxis (SAMBA 2020)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (4)

4 need judgement
  • informationalsevererefractory_postop_vomiting
    Vomiting refractory to 3 classes of antiemetic within 24h (SAMBA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateapfel_high_risk
    Apfel score 3-4 (any 3 of: female, nonsmoker, prior PONV/MS, postop opioids) (Apfel 1999)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehigh_emetogenic_surgery
    Laparoscopic / gynecologic / strabismus / ENT / breast / thoracoscopic surgery (SAMBA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateqt_prolonging_meds_active
    Baseline QTc >450 ms OR on multiple QT-prolonging meds (SAMBA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

PONV — SAMBA 2020 Apfel-matched multimodal prophylaxis + class-different rescue
axis: ponv_apfel_matched_pathwaystep 1 - Step 1 — Baseline risk reduction (regardless of Apfel score, when feasible)
Selected step "Step 1 — Baseline risk reduction (regardless of Apfel score, when feasible)" — Any patient undergoing general anesthesia
  • tiva_propofol_instead_of_volatile_when_high_risk
    first line
    anesthetic_strategy
    Propofol TIVA • IV • continuous
    triggers: apfel_>=2, high_emetogenic_surgery
    TIVA reduces PONV vs volatile (SAMBA 2020)
  • opioid_sparing_multimodal_analgesia
    first line
    analgesia_strategy
    Regional block + NSAID + acetaminophen + ketamine low-dose • multimodal • perioperative
    triggers: apfel_>=1
    Opioids are 1 Apfel point; minimize (SAMBA 2020, Apfel 1999)
  • adequate_iv_hydration_carb_loading_preop
    first line
    hydration_strategy
    20-30 mL/kg crystalloid intraop; preop carbohydrate drink • IV/PO • perioperative
    triggers: apfel_>=1
    Hydration reduces PONV (SAMBA 2020)
  • avoid_nitrous_oxide_when_high_risk
    first line
    anesthetic_strategy
    Omit N2O • inhaled • continuous
    triggers: apfel_>=2
    N2O contributes to PONV at exposures >1h (SAMBA 2020)

outpatient playbook — drug actions (2)

  1. 1. scopolamine patch (high-risk preop)
    rxcui 9601
    1 patch transdermal evening before / 2-4h preop • transdermal • q72h
    trigger: Apfel >=2 + motion sickness history (SAMBA 2020)
    Preop adjunct (SAMBA 2020)
  2. 2. aprepitant (high-risk laparoscopic)
    rxcui 358255
    40 mg PO within 3h preop • PO • once preop
    trigger: Apfel >=3 OR laparoscopic / thoracoscopic (SAMBA 2020)
    NK1 preop dose (SAMBA 2020)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Postoperative nausea (within 24h of anesthesia) (SAMBA 2020); Postoperative vomiting or retching (within 24h of anesthesia) (SAMBA 2020); Apfel score >=2 (female + nonsmoker + prior PONV/motion sickness + postop opioids) (Apfel 1999).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Postoperative Nausea and Vomiting** (anesthesia.ponv-postop-nausea-vomiting.core.v1).
Phenotype framing: Distinguish PONV from postop ileus, opioid effect, bowel obstruction, electrolyte derangement, raised ICP, vestibular cause (SAMBA 2020)
Scope: Confirm PONV scope — risk-stratify pre-induction, deliver multimodal prophylaxis matched to Apfel/Eberhart score, rescue with different drug class if breakthrough (SAMBA 2020)

No severity triggers fired against current inputs.

Plan

Regimen axis: **PONV — SAMBA 2020 Apfel-matched multimodal prophylaxis + class-different rescue** — step "Step 1 — Baseline risk reduction (regardless of Apfel score, when feasible)".
1. tiva_propofol_instead_of_volatile_when_high_risk Propofol TIVA IV continuous (anesthetic_strategy, first line) — TIVA reduces PONV vs volatile (SAMBA 2020)
2. opioid_sparing_multimodal_analgesia Regional block + NSAID + acetaminophen + ketamine low-dose multimodal perioperative (analgesia_strategy, first line) — Opioids are 1 Apfel point; minimize (SAMBA 2020, Apfel 1999)
3. adequate_iv_hydration_carb_loading_preop 20-30 mL/kg crystalloid intraop; preop carbohydrate drink IV/PO perioperative (hydration_strategy, first line) — Hydration reduces PONV (SAMBA 2020)
4. avoid_nitrous_oxide_when_high_risk Omit N2O inhaled continuous (anesthetic_strategy, first line) — N2O contributes to PONV at exposures >1h (SAMBA 2020)

Setting playbook (outpatient) — Preop anesthesia clinic — Apfel/Eberhart risk-stratify, document prophylaxis plan, counsel patient on prior PONV documentation (SAMBA 2020)
5. scopolamine patch (high-risk preop) 1 patch transdermal evening before / 2-4h preop transdermal q72h — Apfel >=2 + motion sickness history (SAMBA 2020) (Preop adjunct (SAMBA 2020))
6. aprepitant (high-risk laparoscopic) 40 mg PO within 3h preop PO once preop — Apfel >=3 OR laparoscopic / thoracoscopic (SAMBA 2020) (NK1 preop dose (SAMBA 2020))

Non-pharmacologic actions:
- Document Apfel score in chart (SAMBA 2020)
- Counsel on multimodal prophylaxis (SAMBA 2020)
- Plan TIVA + opioid-sparing analgesia for high-risk (SAMBA 2020)

AVOID / contraindication checks:
- Droperidol_black_box_QT_prolongation_baseline_ECG_before_use (SAMBA 2020)
- Metoclopramide_avoid_routine_PONV_evidence_weak_consider_EPS_risk (SAMBA 2020)
- Scopolamine_avoid_in_elderly_delirium_and_pediatric_under_age (SAMBA 2020)
- Promethazine_IV_extravasation_tissue_injury_avoid_in_elderly (SAMBA 2020)
- Dopamine_antagonists_avoid_in_parkinsons (SAMBA 2020)
- Do_not_repeat_5HT3_within_6h_rotate_class (SAMBA 2020)
- Aprepitant_PO_within_3h_preop_pediatric_dosing_separate (SAMBA 2020)

Monitoring

Regimen monitoring:
- nausea VAS q1 to 2h PACU (SAMBA 2020)
- vomiting episode count per 24h (SAMBA 2020)
- hydration status intake output (SAMBA 2020)
- electrolytes if refractory vomiting (SAMBA 2020)
- ECG QT if multiple QT active antiemetics (SAMBA 2020)
- aspiration screen post emesis (SAMBA 2020)

Setting (outpatient) monitoring:
- Confirm patient has scopolamine patch / aprepitant on day of surgery (SAMBA 2020)

Follow-up plan: Document PONV event in chart for future anesthetics; counsel re prior-PONV factor and aprepitant prophylaxis for future high-risk surgery (SAMBA 2020)
- Close-out criterion: documentation + counseling complete

Monitoring phase: Nausea VAS, vomiting episodes, hydration, electrolytes if refractory; QT if multiple QT-active antiemetics; aspiration screen (SAMBA 2020)

Disposition

Current setting: outpatient — Preop anesthesia clinic — Apfel/Eberhart risk-stratify, document prophylaxis plan, counsel patient on prior PONV documentation (SAMBA 2020)

Disposition criteria:
- Plan documented for OR team (SAMBA 2020)

Escalation triggers (move to higher acuity):
- New refractory PONV history -> add 3rd-4th class on next anesthetic (SAMBA 2020)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Vomiting refractory to 3 classes of antiemetic within 24h (SAMBA 2020)
- [MODERATE] Apfel score 3-4 (any 3 of: female, nonsmoker, prior PONV/MS, postop opioids) (Apfel 1999)
- [MODERATE] Laparoscopic / gynecologic / strabismus / ENT / breast / thoracoscopic surgery (SAMBA 2020)

Citations

- SAMBA / Fourth Consensus Guidelines for Management of Postoperative Nausea and Vomiting (Gan TJ et al, Anesth Analg 2020) + Apfel CC simplified risk score (Anesthesiology 1999) [PMID:32467512](https://pubmed.ncbi.nlm.nih.gov/32467512/)
- Cited evidence (PMID 10485781) [PMID:10485781](https://pubmed.ncbi.nlm.nih.gov/10485781/)

Last reconciled with current guidelines: 2026-05-26.
References
  • SAMBA / Fourth Consensus Guidelines for Management of Postoperative Nausea and Vomiting (Gan TJ et al, Anesth Analg 2020) + Apfel CC simplified risk score (Anesthesiology 1999) — PMID:32467512
  • Cited evidence (PMID 10485781) — PMID:10485781