Risk-Stratified Antiemetic Prophylaxis and Postoperative Nausea and Vomiting Following Elective Surgery: A Retrospective Secondary Analysis

Abstract

Background: Postoperative nausea and vomiting (PONV) remains one of the most frequently encountered complications following anesthesia and surgery and continues to have an important influence on postoperative comfort and recovery. Although PONV is generally transient, clinically significant symptoms may delay oral intake and mobilization, increase the requirement for rescue medication and nursing observation, and adversely affect patient satisfaction. The occurrence of PONV is multifactorial and is influenced by patient-related characteristics, anesthetic exposure, surgical factors, and postoperative analgesia. The simplified Apfel risk score provides a practical approach to identifying patients at increased risk [1,2]. Contemporary recommendations emphasize risk assessment together with multimodal preventive strategies rather than treatment after symptoms have already developed [1,3].

Objective: The present study was undertaken to evaluate the association between the intensity of prophylactic antiemetic therapy and the occurrence of PONV during the first 24 postoperative hours among adults undergoing elective surgery. A secondary objective was to evaluate the relationship between accumulation of established PONV risk factors and postoperative symptoms and to identify independent factors associated with PONV.

Methods: This retrospective secondary analysis included 220 adult patients who underwent elective surgery under general anesthesia or a general-anesthesia-containing technique during an 12-month period from January 2024 to December 2024. Demographic characteristics, established PONV risk factors, anesthetic exposures, postoperative opioid administration, prophylactic antiemetic therapy, PONV occurrence and timing, and rescue antiemetic requirements were evaluated. Patients were categorized according to prophylactic antiemetic intensity as receiving no prophylaxis, single-agent prophylaxis, or multimodal prophylaxis. PONV incidence was compared across prophylaxis groups and according to the number of established risk factors. Multivariable logistic regression was used to identify factors independently associated with PONV.

Results: PONV occurred in 63 of 220 patients (28.6%) during the first 24 postoperative hours. PONV occurred in 26 of 65 patients (40.0%) who received no prophylaxis, 28 of 91 patients (30.8%) who received single-agent prophylaxis, and 9 of 64 patients (14.1%) who received multimodal prophylaxis (P=0.004). The frequency of PONV increased progressively with accumulation of established risk factors, from 8.7% in patients with no risk factors to 60.0% among those with all four evaluated risk factors (P<0.001). Previous PONV or motion sickness was the strongest independent predictor of PONV (adjusted odds ratio [aOR], 3.42; 95% confidence interval [CI], 1.55–7.55; P=0.002), followed by female sex (aOR, 2.53; 95% CI, 1.27–5.03; P=0.008), postoperative opioid administration (aOR, 2.31; 95% CI, 1.16–4.58; P=0.017), and anesthesia duration >120 minutes (aOR, 1.96; 95% CI, 1.00–3.84; P=0.049). Multimodal prophylaxis was independently associated with lower odds of PONV compared with no prophylaxis (aOR, 0.31; 95% CI, 0.12–0.78; P=0.013).

Conclusion: PONV affected more than one-quarter of patients in this elective surgical population and demonstrated a progressive increase with accumulation of established risk factors. Multimodal prophylactic antiemetic therapy was associated with lower occurrence of PONV compared with no prophylaxis. These findings support systematic perioperative risk assessment, reduction of modifiable emetogenic exposures, and appropriately intensified prophylaxis in patients at increased risk. However, because this was an observational analysis, the findings should be interpreted as associations rather than evidence of a causal treatment effect.