Clinical Calculators

Apfel Score for Postoperative Nausea and Vomiting (PONV)

Estimates the risk of postoperative nausea and vomiting after general anesthesia in adults from the number of four risk factors (1 point each)

4 items left

Female sex
Non-smoker

A person who does not smoke answers "Yes" (1 point). The consensus guideline sets no cut-off for how much smoking makes a person a smoker

History of postoperative nausea and vomiting (PONV) or motion sickness

Answer "Yes" (1 point) for a history of PONV, a history of motion sickness, or both

Postoperative opioid use

Answer "Yes" (1 point) when opioids will be used after the operation. The consensus guideline sets no cut-off for the dose

Cautions

  • Estimates the risk of postoperative nausea and vomiting (PONV) from four risk factors worth 1 point each: female sex, non-smoking, a history of PONV or motion sickness, and postoperative opioid use. The total is 0 to 4 points
  • The original study covered adults who had inhalational anesthesia and received no antiemetic prophylaxis (two centers: Oulu in Finland and Würzburg in Germany). The outcome assessed was nausea or vomiting within 24 hours after surgery
  • In the abstract of the original paper the incidence with 0, 1, 2, 3 and 4 factors is 10%, 21%, 39%, 61% and 79%. The consensus guideline (5th edition) rounds these to about 10%, 20%, 40%, 60% and 80%. The bands on this screen use the rounded values
  • The panel of the consensus guideline (5th edition) classes 0 factors as low risk, 1 to 2 factors as medium risk and 3 or more as high risk. This classification is the panel’s, not a cut-off of the original paper
  • The consensus guideline (5th edition) points out that the threshold for each factor is not defined. It gives no cut-off for the dose of postoperative opioids or the amount of smoking, and a history of PONV depends on the type of the earlier surgery, antiemetic prophylaxis and the anesthetic technique
  • The consensus guideline (5th edition) names the Apfel score and the Koivuranta score as commonly used for inpatients. The Koivuranta score adds an operation time of more than 60 minutes to these four factors
  • According to the consensus guideline (5th edition), PONV prediction models built in adults, such as the Apfel score, are poorly suited to postoperative vomiting in children
  • According to the consensus guideline (5th edition), giving multimodal prophylaxis to everyone is increasingly common, and that approach does not discredit the value of predicting risk

References

  1. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology. 1999;91(3):693-700. (Abstract) (original not seen) PMID: 10485781, DOI: 10.1097/00000542-199909000-00022[Original article]
  2. Gan TJ, Jin Z, Ayad S, Belani KG, Habib AS, Meyer TA, Urman RD, Andrew B, Bergese SD, et al. Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2025. Appendix 1: Full Report (supplementary material). (Appendix 1 Full Report: Results, Guideline 1 (Identify Patients’ Risk for PONV), Risk Scores section (pp. 8-9); Guideline 5, pediatric section (p. 36)) https://cdn-links.lww.com/permalink/aa/f/aa_1_1_2025_09_14_gan_aa-d-25-00465_sdc1.pdf[Guideline]

Checked on: 2026-10-21

Disclaimer

This calculation is intended to support the judgment of healthcare professionals. Results are for reference only; decisions about diagnosis and treatment must be made by the responsible healthcare professional. The values you enter never leave your device.