Postoperative nausea and vomiting (PONV): usefulness of the Apfel-score for identification of high risk patients for PONV

Clinic for Anaesthesia, St. Josefs-Hospital Cloppenburg, Krankenhausstrasse 13, 49661 Cloppenburg, Germany.
Acta anaesthesiologica Belgica 02/2006; 57(4):361-3.
Source: PubMed


Postoperative nausea and vomiting (PONV) still represent an important problem in surgery. Treatment and prevention of PONV requires accurate risk stratification. The simplified Apfel-score includes the four factors female gender, no smoking, postoperative use of opioides and previous PONV or motion-sickness in patients' history. Each of these risk factors is supposed to elevate the PONV-incidence about 20%. The aim of the study was to validate this clinical risk assessment score in patients with high risk for PONV.
In a prospective study 93 patients with high risk preoperative score for PONV (Apfel Score III and IV) were analyzed. Patients and nurses were interviewed using a standardized questionnaire at the time of discharge from the post-anesthesia care unit (PACU) as well as 6 hours and 24 hours after admission to the PACU. General anaesthesia was applied as total intravenous anaesthesia (TIVA) with mivacurium, propofol and remifentanil (no nitrous oxide / FI 02 0.5)
In the group with Apfel score III PONV occurred in 59.7% of patients and in the Apfel score group IV in 91.3% of all patients. The incidence of PONV corresponds to the predicted values of 60% for Apfel III and 80% for Apfel IV although the use of TIVA should have reduced the incidence of PONV about 26%. This apparent overestimation could be explained by the frequent questioning of patients and nurses for PONV leading to assessment of very minor symptoms.
The Apfel-score is a useful and simple tool for stratification of patients with high risk for PONV.

1 Follower
203 Reads
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: A score to predict postoperative vomiting (PV) in children (POVOC score) has recently been published but has not yet undergone an external validation. We studied 673 patients (age 0-16 yr) undergoing a variety of surgical procedures (but excluding strabismus surgery, one of the risk factors according to the POVOC score) using standardized anesthesia techniques without administering antiemetics. The patients were prospectively screened for PV in the postoperative period and these incidences were compared with the predicted risk for PV according to the POVOC score. The POVOC score was evaluated with respect to its ease of use, discrimination, and calibration. Complete data to predict the risk for PV could be obtained in 95% of patients. The actual observed incidences of PV were 3.4, 11.6, 28.2, and 42.3% for the presence of 0, 1, 2, or 3 risk factors, resulting in a regression line with a slope of 0.78 and an offset of 2.37. The area under the receiver operating characteristic curve was 0.72 (95% CI: 0.68-0.76). Using the POVOC score, PV in pediatric patients can be predicted with sufficient accuracy comparable to the results in adult patients, even if one of the risk factors is not applicable.
    Anesthesia and analgesia 01/2008; 105(6):1592-7, table of contents. DOI:10.1213/01.ane.0000287816.44124.03 · 3.47 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Often considered the big little problem, postoperative nausea and vomiting (PONV) is a common surgical complication. Treatment of pain with opioids is the primary cause of PONV although other risk factors include female gender, non smoking status and history of PONV or motion sickness. Research has focused on medications to prevent or treat PONV, and risk factors that contribute to PONV. Genetics may also play a role. The purpose of this study was to explore the association of CYP2D6 and mu-opioid receptor genotypes with PONV in patients with single extremity fractures. Subjects (n=143), aged 18-70 were recruited for this exploratory, descriptive study. Informed consent was obtained. PONV was collected by self-report and chart audit. Saliva samples were collected for DNA extraction. Results of Taqman® allele discrimination were used to assign a CYP2D6 classification of poor metabolizer (PM), intermediate metabolizer (IM) extensive metabolizer (EM) and ultrarapid metabolizer (UM). Two SNPS of the mu-opioid receptor gene were analyzed, A118G and C17T by Polymerace Chain Reaction (PCR). Due to genetic differences within ethnic groups, only Caucasians (n=112) were included in the CYP2D6 analysis. The incidence of PONV in the PACU was 38%, increasing to 50% when assessed for 48 hours. CYP2D6 classification results were: 7 (6%) PM group; 34 (30%) IM group; 71 (63%), EM group; and no ultrarapid metabolizers. Gender and history of PONV were significant risk factors in this study (p<.05). There was a trend for age (p=.071), but smoking was not significant (p=.505). The CYP2D6 EM group served as the reference for binary logistic regression analysis which revealed a significant difference with the CYP2D6 PM group for presence of PONV (p =.003). The sample size for the mu-opioid receptor genotype analysis was 82, the genotype distribution was 58 (70%) AA or CC (wild type) and 24 (30%) polymorphism (AG, GG, CT, or TT were combined). No statistical differences were found in the mu-opioid receptor genotype groups for PONV. Ultimately personalized medicine will allow health care providers to treat all patients individually, so it is important for clinical genetic research to identify those risks that may lead to a negative outcome.
  • Source

Show more


203 Reads
Available from