Abstract

Postoperative nausea and vomiting (PONV) remains a major challenge in anesthesia for high-risk surgical patients. Its complications extend beyond discomfort as increased dehydration, fluid shifts, aspiration risk, and hospital stay duration all reduce patient satisfaction. Research and clinical experience highlight the need for anesthesia providers to move away from single-drug prophylaxis and implement individualized, multimodal strategies for high-risk patients.

Early risk identification is vital. The Apfel score—based on female gender, non-smoking status, history of PONV, and likely opioid use—effectively forecasts risk. An Apfel score of 4 indicates over 80% chance of PONV, so timely prevention is crucial. More than tallying risk though, tailored treatment plans reduce POV rates better than generic, one-size-fits-all protocols. Studies have shown that individualized approaches outperform standardized care, especially in high-risk groups.

Multimodal antiemetic therapy is recognized as the primary approach. Strong evidence supports using drugs that act on different receptor types synergistically. These include 5-HT3 antagonists (ondansetron), corticosteroids (dexamethasone), NK-1 antagonists (aprepitant), along with agents such as droperidol and scopolamine. These combinations lower PONV rates and severity more effectively than single agents. Additionally, research from bariatric and abdominal surgery confirms multimodal regimens succeed regardless of BMI.

Timing of administration is also important. Studies reveal that antiemetics are more effective when given preoperatively or intraoperatively, rather than as rescue therapy. Dexamethasone after intubation and aprepitant before induction maximize this effectiveness. For example, the addition of aprepitant can drop PONV rates from 85% to 59% in high-risk groups, proving the value of proactive interventions over reactive measures.

Overall, risk identification using proven tools, like the Apfel score, should be employed for all surgical patients receiving general anesthesia. Multimodal antiemetic prophylaxis must be standardized for high-risk patients, using agents with complementary mechanisms of actions. Opioid-sparing techniques and non-pharmacological interventions must be utilized to promote positive outcomes.

Author Details

Turner Tinsley, DNP(c), BSN, RN. Two (2) years ER experience; Four (4) years MICU experience 

Sigma Membership

Non-member

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Case Study/Series

Research Approach

Translational Research/Evidence-based Practice

Keywords:

Antiemetics -- Therapeutic Use, Nausea and Vomiting -- Risk Factors, Postoperative Complications, Post-Operative Nausea and Vomiting, Antiemetic Prophylaxis, Multimodal Therapy

Advisor

Cassandra King

Degree

DNP

Degree Grantor

Samford University

Degree Year

2026

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Degree-based Submission

Acquisition

Proxy-submission

Date of Issue

2026-03-18

Full Text of Presentation

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Additional Files

Abstract.pdf (184 kB)

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