Postoperative nausea and vomiting (PONV) : usefulness of the Apfel-score for identification of high risk patients for PONV.
ABSTRACT 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.
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ABSTRACT: A number of perioperative risk factors may suppress the immune system and contribute to the development of post-operative complications. The association between surgical site infection (SSI) and other wound-related complications resulting from immunosuppression through either perioperative administration of dexamethasone, pre-operative smoking or alcohol abuse is, however, uncertain. This study was a post hoc analysis of data from the PROXI randomized trial in 1386 patients who underwent emergency or elective laparotomy. We assessed the associations of use of dexamethasone, smoking status and alcohol abuse with the primary outcome, being a composite of SSI, anastomotic leak, wound dehiscence, burst abdomen and 30-day mortality. The primary outcome occurred in 21% of patients receiving dexamethasone versus 28% of patients not receiving dexamethasone, and this was not statistically significant when adjusting for stratification variables originally used in the PROXI trial [OR 0.90, 95% CI (0.65-1.24)]. In smokers, the primary outcome occurred in 32%, compared with 23% of non-smokers (P = 0.0001). Smokers also had a higher frequency of SSI (25% vs 17%, P < 0.0001) and burst abdomen (3.8% vs 2.4%, P = 0.04). In alcohol abusers, the primary outcome occurred in 48%, compared with 25% in patients who did not abuse alcohol (P = 0.0006). Burst abdomen occurred more commonly in alcohol abusers (15% vs 2.3%, P < 0.0001). Perioperative administration of dexamethasone was not significantly associated with SSI or other wound-related complications. Conversely, smoking and alcohol abuse were both significant predictors of the primary outcome consisting of wound-related complications and mortality.Acta Anaesthesiologica Scandinavica 02/2014; · 2.36 Impact Factor
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ABSTRACT: Background: One of the modalities of treatment for breast cancer surgery pain is opioids, and opioids are associated with adverse effects such as itching and postoperative nausea and vomiting (PONV). Intravenous (IV) lidocaine has been shown to reduce opioid consumption and to improve overall postoperative outcomes in abdominal surgery. In this study, we tested the effect of intraoperative IV lidocaine infusion on the quality of postoperative recovery after breast cancer surgery. Methods: Seventy-one patients undergoing breast cancer surgery were randomly assigned to receive either placebo (group P; n = 34) or IV lidocaine (group L; n = 37, bolus 1.5 mg/kg at induction, then infusion at 2 mg/kg/h, stopped 2 hours after the end of surgery) in a prospective double-blind design. Intraoperative and postoperative morphine consumption was calculated. Postoperative pain scores, PONV, and fatigue were assessed at 2, 24, and 48 hours after surgery. Duration of postoperative hospital stay was recorded. Results: Demographics were the same between the groups. There was no statistically significant difference in intraoperative or postoperative morphine consumption (P = 0.188 and P = 0.758) between groups. Overall pain scores either at rest or activity (P = 0.348 and P = 0.810, respectively), PONV (P = 0.350), fatigue (P = 0.758), or duration of postoperative hospital stay (P = 0.218) were not statistically different. Conclusions: Our findings did not show a significant effect of IV lidocaine during breast cancer surgery on opioid consumption, pain score, PONV, or fatigue, indicating that the benefit of this approach does not generalize across all types of surgery.Regional Anesthesia and Pain Medicine 10/2014; · 2.12 Impact Factor
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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. · 3.42 Impact Factor
© Acta Anæsthesiologica Belgica, 2006, 57, n° 4
Abstract : Objective : Postoperative nausea and vomit-
ing (PONV) still represent an important problem in sur-
gery. Treatment and prevention of PONV requires accu-
rate 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
Methods : 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 dis-
charge 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 O2 0.5)
Results : 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.
Conclusion : The Apfel-score is a useful and simple tool
for stratification of patients with high risk for PONV.
Key words : Postoperative nausea and vomiting ;
PONV ; Apfel-score.
25-30% of all patients who undergo surgery
will experience postoperative nausea and vomiting
(PONV) (1,4). Risk factors for PONV have been
described and include female gender, no smoking,
postoperative use of opioides and previous PONV
or motion-sickness in patients’history” (5, 7). Each
factor elevates the risk of PONV about 20%. These
factors have been summarized in the simplified
PONV-risk score (Table 1), the “Apfel-score” (3, 2).
It has been described recently that treatment
with ondasetrone as well as dexamethasone or
droperidol may reduce the incidence of PONV by
about 26%, propofol by 19% and anaesthesia with-
out nitrous oxide by 12% (1). The reduction of
PONV by the use of total intravenous anesthesia
(TIVA) with propofol and without nitrous oxide
was thus similar to that observed with each of the
antiemetic drugs. Patients with high risk score
(Apfel III or IV, i.e. 60-80% risk for PONV) require
multimodal treatment with more than one antiemet-
ic agent (2). A multimodal approach for prevention
and treatment of patients with high risk for PONV
requires accurate prediction. In the prospective
study presented herein we describe the validation of
the PONV risk assessment score by Apfel in
patients with high risk for development of PONV.
Ninety-three consecutive patients with high
risk for PONV (Apfel-score III and IV) (2), under-
going a wide range of elective surgery under gener-
al anesthesia were enrolled in this study. Inclusion
criteria were age 18-80 yr and ASA-score I-III.
Exclusion criteria were vomiting before anesthesia
and severe postoperative complication like myocar-
dial infarction. The age ranged from 20-79 yr. The
(Acta Anaesth. Belg., 2006, 57, 361-363)
Postoperative Nausea and Vomiting (PONV) : Usefulness of the
Apfel-Score for identification of high risk patients for PONV
C. WEILBACH (*), N. RAHE-MEYER (**), K. RAYMONDOS (**),A. WEISSIG (**), D. SCHEINICHEN (**) and
S. PIEPENBROCK (**)
C. WEILBACH, M.D. ; N. RAHE-MEYER, M.D. ; K. RAYMONDOS,
M.D. ; A. WEISSIG, M.D. ; D. SCHEINICHEN, M.D. ; S.
(*) Clinic for Anaesthesia, St. Josefs-Hospital Cloppenburg,
Krankenhausstraße 13, 49661 Cloppenburg, Germany.
(**) Clinic for Anaesthesia, Medical School Hannover, Carl-
Neuberg-Straße 1, 30625 Hannover, Germany.
Tel. : 49511 5322489.
Correspondence address : Dr C. Weilbach, Krankenhaus-
straße 13, 49661 Cloppenburg, Germany.
Tel. : 494471 161500. Fax : 494471 161507.
E-mail : email@example.com.
© Acta Anæsthesiologica Belgica, 2006, 57, n°4
C. WEILBACH et al.
study protocol was approved by the local ethics
committee for human studies (Ärztekammer
Niedersachsen / Hannover, Germany).
Using a standardized questionaire patients and
nurses were interviewed by the anesthesiologist at
the time of discharge from the post-anesthesia care
unit (PACU) and 6 h and 24 h after admission to the
PACU by the anestesiologist. Total intravenous
anesthesia (TIVA) was performed in all patients
with propofol and remifantanil without nitrous
oxide and with FiO2 of 0.5. Nausea was scored by
a 100-point numerical scale from 0-100, where zero
represents no nausea and 100 representing nausea
“as bad as it can possibly be”.
Statistical analysis : Data are given as mean ±
SD, differences between groups were analyzed
using the Mann-Whitney-U-Test.
The high risk groups Apfel III and IV were
equally distributed in the study population. Patient
characteristics are shown in table 2. For all para-
meters analyzed i.e. age, the ASA-Score (ASA I
32,3%, ASA II 63,4%, ASA III 4,3%) duration of
surgery as well as time spent in the PACU no signif-
icant differences were found between the study
groups. The vast majority of patients with high risk
for PONV were women consisting of 98.9% of all
PONV occurred in the group Apfel III in
59.7% and in the group Apfel IV in 91,3%, all
results are shown in table 3.
In this trial the occurrence of nausea and vom-
iting in 59,7% (Apfel III) and 91,3% (Apfel IV) of
all patients. The predicted range was 60% for Apfel
III and 80% for Apfel IV. These predictions howev-
er are based on anaesthesia method that includes
volatile anaesthetics as well as nitrous oxide. In our
study total intravenous anaesthesia with propofol,
remifentanil without nitrous oxide was applied.
This should have reduced the occurrence of PONV
by 26% (1). Thus, the real incidence of PONV in
our patients appears to be higher than expected.
This may be due to the fact that we questioned
patients as well as nurses three times within the first
24 hours postoperatively for symptoms of PONV.
In the largest study so far (1) the incidence of
PONV was measured by interviewing the patients
only at 2ndand 24thhour postoperatively. This
methodological difference in measurement of
PONV may have let to an overestimation of PONV
in our patients with assessment of very mild symp-
toms. It may be considered unethical to leave
patients with high risk for PONV without addition-
al treatment, except TIVA. This issue was discussed
with the local ethics committee. But, viewing the
limited efficacy of each single drug in prevention
and treatment of PONV and the need for a simple
and effective predictive score for accurate applica-
tion of a multimodal treatment including antiemet-
ic drugs we decided to start the study. One limita-
tion of this study is that patients with lower risk for
PONV were not included making a general calcula-
tion of sensitivity and specificity and receiver oper-
ating characteristic curves impossible (6). The
intention of this study however was to evaluate if
patients with very high risk for PONV could be
identified prior to operation with a simple clinical
score. Viewing that almost all patients with Apfel
Risk-estimation for PONV by the Apfel-score
Risk estimation (%)
20 (%) 40 (%)60 (%)80 (%)
Risk factors (each one “Risk-poin”t)
1 point female gender
1 point no smoking
1 point postoperative use of opioides
1 point previous PONV or motion-sickness in patients’ history.
(n = 47)
(n = 46)
Median ± standard
Median ± standard
52,8 ± 15,1
27,5 ± 5,0
60,8 ± 32,9
88,0 ± 37,4
55,6 ± 11,8
26,3 ± 5,6
59,6 ± 33,0
89,9 ± 34,5
Incidence (total) of PONV
PONVApfel IIIApfel IV
no nausea / no vomitino
nausea and vomiting
nausea score mean ±
27,84 ± 29,2514,67 ± 19,53
© Acta Anæsthesiologica Belgica, 2006, 57, n°4
IV score indeed experienced PONV we believe that
the Apfel score is an acceptable clinical tool for this
purpose. This high risk population should therefore
benefit from a multimodal PONV treatment includ-
ing perioperative therapy with dexamethasone,
droperidol, ondasetrone, haloperidol and total intra-
venous anesthesia. In addition, therapy of postoper-
ative pain in such patients should be critically
reviewed and alternative treatment strategies
including regional anaesthetics and omission of
opiates reconsidered. Such prophylactic multi-
modal approach requires correct risk assessment. In
conclusion our study confirms that the Apfel risk
assessment score for PONV is a simple and reliable
test to identify patients at high risk and could thus
be used for development of preventive treatment
We express our gratitude to all participating
physicians and Heinz Geerlings for help with statis-
No competing interests to delcare
Christian Weilbach designed and analyzed the
study, wrote the manuscript and is fully responsible
for the scientific content, Niels Rahe-Meyer,
Annette Weissig, Kostas Raymondos and Dirk
Scheinichen monitoring of patients and data man-
agement, Siegfried Piepenbrock : study design and
1. Apfel C. C., Korttila K., Abdalla M., et al., A factorial trial
of six interventions for the prevention of postoperative
nausea and vomiting, N. ENGL. J. MED., 350, 2441-2451,
2. Apfel C. C., Kranke P., Eberhart L. H., et al., Comparison of
predictive models for postoperative nausea and vomiting,
BR. J. ANAESTH., 88, 234-240, 2002.
3. Apfel C. C., Roewer N., Risk assessment of postoperative
nausea and vomiting, INT. ANESTHESIOL. CLIN., 41, 13-32,
4. Gan T., Meyer T., Apfel C. C., et al., Consensus guidelines
for managing postoperative nausea and vomiting, ANESTH.
ANALG., 97, 62-71, 2003. table of contents.
5. Sinclair D. R., Chung F., Mezei G., Can postoperative nau-
sea and vomiting be predicted ?, ANESTHESIOLOGY, 91, 109-
6. Van den Bosch J. E., Kalkman C. J., Vergouwe Y., Van
Klei E.A., Bonsel G. J., Grobbee D. E., Moons K. G. M.,
Assessing the Applicability of scoring systems for predicting
postoperative nausea and vomiting, ANAESTHESIA, 60, 323-
7. Watcha M. F., The cost-effective management of postopera-
tive nausea and vomiting, ANESTHESIOLOGY, 92, 931-933,
VALIDATION OF THE APFEL-SCORE (PONV) 363