Association Between Digit Ratio and Postoperative Nausea and Vomiting: A Single-Center Prospective Cohort Study.

We have validated two scoring systems for predicting postoperative nausea and vomiting, derived by Apfel et al. and Koivuranta et al. from 1388 adult inpatients undergoing a wide range of surgical procedures. The predictive accuracy of the scoring systems was evaluated in terms of the ability to discriminate between patients with and without postoperative nausea and vomiting (discrimination) and agreement between observed and predicted outcomes (calibration). Discrimination and calibration were less than expected based on previous reports, with both scoring systems providing risk predictions that were too extreme. The area under the ROC curve was 0.63 for Apfel et al.'s scoring system and 0.66 for Koivuranta et al.'s scoring system. Neither of the scoring systems provided a risk threshold for administering anti-emetic prophylaxis that yielded satisfying results in terms of predictive values, sensitivity and specificity. Hence, in their original forms, the scoring systems do not guarantee accurate prediction of the risk of postoperative nausea and vomiting in other patient populations. Koivuranta et al.'s scoring system appears to be more robust across different populations.

Postoperative nausea and vomiting (PONV) is usually defined as any nausea, retching, or vomiting occurring within the first 24–48 hours of surgery. PONV can be extremely distressing to patients and is one of the most common causes of patient dissatisfaction and discomfort after anesthesia. The average incidence of PONV after general anesthesia is about 30% in all post-surgical patients but up to 80% in high-risk patients despite advances in anesthetics and anesthesia techniques [1,2,3]. In addition, PONV is rated highly in preoperative surveys, as the clinical anesthesia outcome that the patient would most like to avoid [4]. Therefore it is not surprising that patients express a high willingness-to-pay ($50–100) to avoid PONV [5,6]. While bleeding, wound dehiscence, pulmonary aspiration of gastric contents, esophageal perforation, and other serious complications associated with PONV are rare, nausea and vomiting is still an unpleasant, unwanted and all-too-common postoperative morbidity that can delay patient discharge from the postanesthesia care unit, require expanded levels of nursing care and increase unanticipated overnight hospital admissions in outpatients. The public now believes that anesthesia is extraordinarily safe from catastrophic outcomes, including major organ dysfunction or failure and even death. Therefore, many patients are more concerned about pain and PONV than surgical outcomes, such as whether the surgery would improve their condition. This is especially true for the majority of patients undergoing less invasive surgery. Moreover, minimally invasive surgery is now increasingly and routinely used across almost all surgical specializations. An important aspect of the quality of anesthetic care is the satisfaction of the patient with their care. Possible strategies to prevent the incidence of PONV include the prophylactic use of antiemetics such as dexamethasone or 5-HT3 antagonists, and avoiding use of emetic drugs such as inhalational anesthetics or opioids. However, no drug is completely effective at preventing PONV. If we can avoid drugs that cause PONV, all the better. The etiology of PONV remains unclear, but involves anesthetic, surgical and patient factors. Well-known risk factors are female gender, non-smoking status, a history of motion sickness or previous PONV, inhalational anesthetics, certain types of surgery, and opioid use [7]. Among the risk factors for PONV, the use of postoperative opioids is one of four major risk factors in the simplified risk-scoring system introduced by Apfel et al. [8]. In this month's Korean Journal of Anesthesiology, Lim et al. [9] report a study focusing on the effects of intraoperative opioid use on the incidence and severity of PONV and the effects of a single bolus administration of fentanyl during anesthesia induction versus intraoperative infusion of remifentanil on PONV. In a previous randomized controlled trial in over 5000 patients, the use of a short-acting opioid, like remifentanil, instead of fentanyl did not decrease the incidence of PONV [10]. However, in that study, patients who had been assigned to receive intraoperative remifentanil were given 50 µg of morphine per kilogram or an equivalent opioid at the end of surgery. Therefore, the current study has meaningful results based on comparing only fentanyl versus remifentanil itself, without the other factors that affect PONV. They demonstrated that a single bolus administration of fentanyl during anesthesia induction increased the incidence of PONV, while an intraoperative remifentanil infusion did not affect the incidence and severity of PONV. These results should have a marked synergistic effect with antiemetic prophylaxis. It should be kept in mind that even a single bolus administration of fentanyl during anesthesia induction can increase the incidence of PONV in high-risk patients.

We’re Tired of Waiting

Postoperative Nausea and Vomiting: Prophylaxis Versus Treatment

Postoperative nausea and vomiting (PONV) are common and distressing postsurgical symptoms [1] which continue to be a significant concern for anesthesiologists. PONV occurs in 20% to 30% of the general population underwent surgery and in up to 70% to 80% of high risk patients [2,3]. PONV is a complex physiologic phenomenon involving multiple neurophysiologic pathways with both central and peripheral receptor mechanisms. A variety of factors have been associated with an increased incidence of postoperative nausea and vomiting. The most frequently described patient-specific risk factors for PONV are female gender, non-smokers, types of surgery such as laparoscopic surgery [4,5] or head and neck surgery, previous history of PONV or motion sickness, and use of intra-operative or postoperative opioids [3]. Postoperative analgesia with opioids is associated with an incidence of PONV of over 30% [6]. Thyroidectomy is also associated with a relatively high incidence of PONV. The incidence of PONV after thyroidectomy has a reporting rate of 60-76% according to previous study [7]. PONV after thyroidectomy surgery might be the main source of discomfort, and it may be perceived as the most unpleasant aspect of postoperative recovery [8]. Being able to identify patient-specific risk factors should help clinicians determine appropriate prophylactic treatment for PONV. Many clinicians have used different types of anti-emetics such as anticholinergic drug, 5-hydroxytryptamine 3 (5-HT3) antagonist or NK-1 antagonist for the treatment of PONV. Ramosetron is a newly developed 5-HT3 receptors antagonist with a more potent and longer receptor antagonizing effect compared with other 5-HT3 receptors antagonists [9]. In this issue of the Korean Journal of Anesthesiology, Lee et al. [10] report on the antiemetic effect of ramosetron with thyroidectomy for PONV. This clinical trial demonstrates the preventative effect of ramosetron for PONV in women undergoing total thyroidectomy with propofol-based total intravenous anesthesia (TIVA). The authors concluded that ramosetron was effective at reducing the incidence and severity of postoperative nausea in women that underwent total thyroidectomy with propofol-based TIVA during first 6 hours postoperatively. Nevertheless there are some debatable points in this paper. The incidences of postoperative nausea in the control and the ramosetron groups were 29% and 12% during first 6 postoperative hours respectively. From a statistical point of view, ramosetron is obviously more effective than control during first 6 postoperative hours (P = 0.029). But there were no differences between ramosetron and control (saline) after 6 hours postoperatively. Also postoperative vomiting was not different all time periods on both groups. The incidence of PONV on the control group was not that high and widely different compared to the ramosetron group in this study as the authors mentioned. While many practitioners believe that 5-HT3 antagonists are relatively safe medications, it is uncertain whether the antiemetic effects of 5-HT3 antagonists are better than inexpensive drugs such as droperidol or metoclopramide clinically. There is also uncertainty about benefit of ramosetron in patients undergoing TIVA. Cost-effective management is often referred to as an important medical issue. Recently, medical budgets are not sufficient for medical services of all patients in our country. Therefore, we need to be concerned about reduction of medical costs. In Korea, ramosetron (approximately US $55 for 0.3 mg) is much more expensive than other commonly used antiemetics, such as metoclopramide. Many risk scoring systems for predicting PONV have been mentioned at present [3]. An evaluation of these risk factors allows clinicians to appropriately plan for prophylaxis and treatment of PONV. Eberhart suggests the use of simplified algorithms that could lead to a benefit for a larger proportion of patients [11]. Clearly, such a risk score-adapted preventive strategy for PONV may be viewed as an efficient method for PONV treatment. The first strategy in reducing the incidence of postoperative nausea and vomiting is to reduce the baseline risk factors for each patient. Patients with a low risk of PONV generally do not require prophylactic medication. Patients at moderate or high risk should receive antiemetic therapy with high cost-effective drugs. Additionally, inexpensive and comprehensive multimodal managements for preventing PONV should be considered perioperatively. The use of propofol and the avoidance of nitrous oxide add to reductions of the incidence of PONV [12,13]. Other simple methods such as maintaining adequate hydration, minimizing the use of opioid analgesics for preventing postoperative pain in high risk patients, and P-6 acupoint stimulation [14] are also available.

Postoperative nausea and vomiting (PONV) is nowadays the most common adverse effect of anesthesia with an incidence of 30% in ageneral postsurgical population. According to studies, most patients concerned appraise PONV as even more undesirable than postoperative pain. The avoidance of PONV through avalid and structured preoperative risk evaluation and asuitable PONV prophylaxis is part of aquality standard of modern anesthetic regimens. In our department of anesthesiology and intensive care medicine, anew standard operating procedure (SOP) for the preoperative estimation of the risk of PONV according to the Apfel score and to the structured prophylaxis and treatment was implemented in September 2022. 1.To what extent is the SOP applied in the daily clinical routine? 2.What impact does the implementation of anew SOP have on the incidence of PONV in apopulation of patients under PONV prophylaxis as compared to atreatment which was noncompliant to the SOP? In this study 2000 retrospective anesthesia data of patients who underwent aroutinely scheduled elective surgery under full anesthesia in the departments of otorhinolaryngology, ophthalmology, gynecology, urology, neurosurgery, orthopedic surgery and visceral surgery were analyzed regarding the preoperative evaluation for risk factors, the intraoperative use of prophylactic agents and the incidence of PONV in the postanesthesia care unit as well as at the surgical ward up to 24 h postoperatively. Data of 1880 adult patients and 120 pediatric patients aged 14years and younger were examined. All in all, the adherence to the new PONV SOP was 46.3%. The chance for aprophylaxis concurrent with the SOP was increased by notification of the preoperative Apfel score as well as by mentioning the indicated PONV prophylaxis in the preoperatively scheduled anesthesia regimen. Prophylaxis and treatment according to the new PONV SOP led to adecrease in the relative PONV risk by 29% as well as in the need for antiemetic rescue medication by 26% in adult patients. The PONV incidence was significantly reduced postoperatively in the surgical ward (p = 0.048) and in the high-risk patient population with an Apfel score of three or four PONV risk factors (p < 0.001). In addition, the need for antiemetic rescue medication 24 h postoperatively significantly decreased in the high-risk group (p = 0.008). In the small population of pediatric patients the recommendation of preoperative evaluation for PONV risk was translated into practice in 7.5%. Astructured SOP regarding the prophylaxis of PONV is asuitable measure to reduce the incidence of PONV and the postoperative need of antiemetic rescue agents, especially in high-risk populations. Nevertheless, further actions have to be taken to increase the adherence to SOPs and to ensure asufficient coverage of prophylactic medication in vulnerable patient groups. According to our data, more attention needs to be directed to the issue of PONV risk and prophylaxis, particularly in pediatric patients.

Preventing and treating both postoperative pain and postoperative nausea and vomiting (PONV) are critical for anesthesiologists to promote successful recovery and improve patient outcomes. PONV is a common side effect of anesthesia and surgery, affecting approximately 30% of patients undergoing surgery and up to 80% of high-risk patients [1, 2] . Untreated PONV can lead to various complications, including increased risk of postoperative bleeding, delayed wound healing, wound dehiscence, gastric aspiration, and electrolyte imbalances such as dehydration and metabolic disturbances [3] . Additionally, PONV can have a significant impact on the patient's experience, leading to prolonged hospital stays, increased healthcare costs, and a considerable disruption of daily life [4] . Therefore, the effective management of PONV is crucial to minimize patient discomfort, reduce healthcare costs, and improve overall patient satisfaction and outcomes. Various antiemetic agents have been developed and tested to prevent PONV, including corticosteroids, 5-HT 3 receptor antagonists, antihistamines, antidopaminergics, and neurokinin-1 receptor antagonists. Although these agents can be effective at reducing the occurrence of PONV, none is capable of fully preventing PONV owing to the various causes of PONV. Therefore, a multimodal approach involving the use of multiple antiemetic agents with different mechanisms of action along with non-pharmacological interventions such as preoperative fasting, intraoperative fluid management, and the use of regional anesthesia techniques, is often recommended [5] . Furthermore, identifying patients at high risk of developing PONV and initiating preventative measures early can also help to decrease the occurrence of PONV. Recent consensus-based guidelines suggest assessing risk factors (i.e., female sex, postoperative opioid administration, non-smoking status, a history of PONV or motion sickness, young patient age, longer duration of anesthesia, volatile anesthetics, and type of surgery) and reducing the patient's baseline risk [6] . However, most studies on PONV have primarily focused on patients receiving general anesthesia, and the majority of information regarding PONV risk factors has been derived from this patient population [5, 7] . In this issue of the Korean Journal of Anesthesiology, Ju et al. [8] conducted a retrospective analysis of a large cohort of 5,691 patients who underwent orthopedic surgery under spinal anesthesia to determine whether the Apfel score, a tool commonly used to predict the likelihood of PONV based on four risk factors (female sex, history of motion sickness or PONV, non-smoking status, and use of postoperative opioids) remains a valid predictor of PONV during spinal anesthesia. The study found that the Apfel score does remain a valid predictor of PONV after spinal anesthesia and that baseline heart rate, non-smoking status, and postoperative opioid use were significant risk factors for PONV after spinal anesthesia. The multivariate analysis revealed an independent association between the overall incidence of PONV and baseline heart rate ≥ 60 beats/min (OR: 1.

ystematic reviews provide the best estimates ofthe true effects (both beneficial and adverse) ofmedical interventions (1). In this era of evidence-based medicine, clinicians are increasingly using sys-tematic reviews to keep up with new evidence and toguide their clinical decision-making. Yet the mainchallenges for clinicians are to translate the results ofsystematic reviews into clinical practice and to pro-vide optimal patient care. This concept is known as“applicability.” Applicability addresses whether aparticular treatment that showed an overall benefit ina study or systematic review can be expected to con-vey the same benefit to an individual patient (2).This paper outlines a framework for how quantita-tive systematic reviews (meta-analyses) should be re-ported and how they may be used to identify thoseindividuals in whom the treatment is likely to do moregood than harm. We illustrate the concepts by usingdata from systematic reviews of ondansetron for thetreatment and prevention of postoperative nausea andvomiting (PONV). Throughout this paper, we use theterms “baseline” and “underlying risk” interchange-ably. Underlying risk is defined as the risk of event fora patient under the control condition; it indicates theaverage risk of a patient if not treated (3).

BackgroundPalonosetron is a new, potent, and long-acting 5HT3-receptors antagonist that had been approved by the FDA for use in postoperative nausea and vomiting (PONV) prophylaxis. This study is designed to evaluate its efficacy combined with dexamethasone in PONV prophylaxis in highrisk patients scheduled for laparoscopic surgeries.MethodsIn this double-blind, active-controlled study, 150 patients aged 20–55 years, ASA I–II, and with Apfel’s PONV score 2–4 were equally randomized to receive dexamethasone 8 mg before anesthesia induction and saline 30 min before the end of surgery (group D + S), dexamethasone 8 mg before anesthesia induction and metoclopramide 25 mg 30 min before the end of surgery (group D + M), or dexamethasone 8 mg combined with palonosetron 0.075 mg before anesthesia induction and saline 30 min before the end of surgery (group D + P). Incidences of early and late PONV, complete response, adverse events from antiemetics used, and overall patients’ satisfaction were recorded.ResultsThe incidence of PONV was comparable in the three groups 0–6 h postoperatively. Palonosetron–dexamethasone and dexamethasone–metoclopramide combination therapies significantly reduced the incidence of PONV at 6–12 h postoperatively compared to dexamethasone monotherapy (12% and 16%, vs. 36%, respectively, with P < 0.05). Moreover, palonosetron–dexamethasone combination therapy significantly reduced the incidence of PONV at 12–24 h postoperatively compared to both dexamethasone monotherapy (16% vs. 48%, P < 0.01), and dexamethasone–metoclopramide combination therapy (16% vs. 40%, P < 0.05). The incidence of adverse drug effects was comparable in the three groups. The overall patients’ satisfaction was significantly higher in palonosetron–dexamethasone combination therapy compared to other groups.ConclusionPalonosetron–dexamethasone combination is effective and safe in PONV (early and late) prophylaxis in high-risk patients undergoing laparoscopic surgeries with known high-risk of PONV.

Postoperative nausea and vomiting (PONV) in pediatric patients is a common and clinically significant postoperative complication. The incidence of PONV has not been extensively studied in large pediatric cohorts. Furthermore, in 2020, the Fourth Consensus Guidelines for the management of PONV were published. However, the association between perioperative factors and adherence to these guidelines remains unclear. This study aims to assess both the incidence of PONV and guideline adherence within a large and diverse pediatric population. We conducted a retrospective observational study at a large tertiary medical center, including pediatric patients (≤18 years) who underwent surgery between September 2020 and March 2023. We conducted a retrospective analysis of data from our electronic health records, focusing on patient demographics, surgical details, anesthesia details, and prophylaxis for PONV. We calculated the incidence of PONV and used multivariable logistic regression to identify the predictors of guideline adherence. The cohort included 3772 patients with a median (interquartile range [IQR]) age of 9.21 (3.55-14.68) years. The incidence (95% confidence intervals) of early PONV was 1.0% (0.7-1.4) and 3.8% (3.2-4.5) for delayed PONV. Adherence to the fourth consensus guidelines for PONV management was observed in 32.5% (31.0-34.0) of cases. A high risk of PONV was identified in 55.9% (54.3-57.5) of the patients. The most common number of PONV risk factors was 3, observed in 1151 patients (30.5% [29.1-32.0]). Significant predictors of guideline adherence included the intraoperative use of long-acting opioids (odds ratio [OR], 2.711, P < .001) and age ≥3 years (OR, 2.074, P < .001). Nonadherence was associated with a higher incidence of PONV at 24 hours postsurgery (4.4% (3.6-5.2) vs 2.7% (1.9-3.8), P = .012). Factors such as specific high PONV risk surgeries ( P = .001), maintenance with inhalational agents solely ( P = .017), and neostigmine use ( P < .001) were also all statistically significant. Our study revealed a lower-than-expected incidence of PONV in pediatric patients, highlighting the need for standardized definitions and improved reporting. Adherence to PONV guidelines was suboptimal, emphasizing the need for better implementation strategies.

PurposeWe evaluated the incidence and risk factors of postoperative nausea and vomiting (PONV) in patients with fentanyl-based intravenous patient-controlled analgesia (IV-PCA) and single antiemetic prophylaxis of 5-hydroxytryptamine type 3 (5 HT3)-receptor antagonist after the general anesthesia.Materials and MethodsIn this retrospective study, incidence and risk factors for PONV were evaluated with fentanyl IV-PCA during postoperative 48 hours after various surgeries.ResultsFour hundred-forty patients (23%) of 1878 had showed PONV. PCA was discontinued temporarily in 268 patients (14%), mostly due to PONV (88% of 268 patients). In multivariate analysis, female, non-smoker, history of motion sickness or PONV, long duration of anesthesia (>180 min), use of desflurane and intraoperative remifentanil infusion were independent risk factors for PONV. If one, two, three, four, five, or six of these risk factors were present, the incidences of PONV were 18%, 19%, 22%, 31%, 42%, or 50%. Laparoscopic surgery and higher dose of fentanyl were not risk factors for PONV.ConclusionDespite antiemetic prophylaxis with 5 HT3-receptor antagonist, 23% of patients with fentanyl-based IV-PCA after general anesthesia showed PONV. Long duration of anesthesia and use of desflurane were identified as risk factors, in addition to risk factors of Apfel's score (female, non-smoker, history of motion sickness or PONV). Also, intraoperative remifentanil infusion was risk factor independent of postoperative opioid use. As the incidence of PONV was up to 50% according to the number of risk factors, risk-adapted, multimodal or combination therapy should be applied.

Background and Aims: Postoperative nausea and vomiting (PONV) still present an important problem in anesthesia. In order to identify surgical patients who may benefit from prophylactic antiemetic medication, it is of interest to evaluate the risk factors for PONV using a simple scoring system. The simplified Apfel score includes four factors: female gender, nonsmoking status, postoperative use of opioids, and previous history of PONV or motion sickness. Each of these risk factors is supposed to elevate the incidence of PONV by about 20%. The aim of this study was to validate Apfel's clinical risk assessment score for identification of patients with high risk for PONV in our hospital. Materials and Methods: In a prospective study, 150 patients posted for various elective surgeries under general anesthesia with endotracheal intubation were analyzed and grouped into five groups, based on the Apfel risk scoring system. Each risk was given a score of 1, the total score being 4. PONV was monitored for 24 h and classified as grades 0, 1, and 2. Grades 1 and 2 were considered as PONV. The results obtained were analyzed for total incidence of PONV in each group of Apfel's scores and they were compared with the predicted incidence of PONV as per the documented Apfel's risk assessment. Collected data were analyzed by the Chi-square test, and the scoring system was assessed for sensitivity and specificity. Results: Of the 150 patients assessed, a total of 42% had PONV. Patients grouped under Apfel Score I had PONV incidence of 25.5%, the group with Score II had an incidence of 37.8%, the group with Score III had 64.6%, and the group with Score IV had 83.3%. This incidence of PONV corresponded to the predicted approximate values of 20% for Apfel Score I, 40% for Apfel II, 60% for Apfel III, and 80% for Apfel IV. Conclusions: The Apfel scoring system is simple and useful for identifying patients with high risk for PONV.

Relationship between the incidence and risk factors of postoperative nausea and vomiting in patients with intravenous patient-controlled analgesia

Postoperative nausea and vomiting (PONV) prophylaxis is consistently considered a key indicator of anesthesia care quality. PONV may disproportionately impact disadvantaged patients. The primary objectives of this study were to examine the associations between sociodemographic factors and the incidence of PONV and clinician adherence to a PONV prophylaxis protocol. We conducted a retrospective analysis of all patients eligible for an institution-specific PONV prophylaxis protocol (2015-2017). Sociodemographic and PONV risk data were collected. Primary outcomes were PONV incidence and clinician adherence to PONV prophylaxis protocol. We used descriptive statistics to compare sociodemographics, procedural characteristics, and protocol adherence for patients with and without PONV. Multivariable logistic regression analysis followed by Tukey-Kramer correction for multiple comparisons was used to test for associations between patient sociodemographics, procedural characteristics, PONV risk, and (1) PONV incidence and (2) adherence to PONV prophylaxis protocol. Within the 8384 patient sample, Black patients had a 17% lower risk of PONV than White patients (adjusted odds ratio [aOR], 0.83; 95% confidence interval [CI], 0.73-0.95; P = .006). When there was adherence to the PONV prophylaxis protocol, Black patients were less likely to experience PONV compared to White patients (aOR, 0.81; 95% CI, 0.70-0.93; P = .003). When there was adherence to the protocol, patients with Medicaid were less likely to experience PONV compared to privately insured patients (aOR, 0.72; 95% CI, 0.64-1.04; P = .017). When the protocol was followed for high-risk patients, Hispanic patients were more likely to experience PONV than White patients (aOR, 2.96; 95% CI, 1.18-7.42; adjusted P = .022). Compared to White patients, protocol adherence was lower for Black patients with moderate (aOR, 0.76; 95% CI, 0.64-0.91; P = .003) and high risk (aOR, 0.57; 95% CI, 0.42-0.78; P = .0004). Racial and sociodemographic disparities exist in the incidence of PONV and clinician adherence to a PONV prophylaxis protocol. Awareness of such disparities in PONV prophylaxis could improve the quality of perioperative care.

In the last decade, anaesthesia practice has changed at Landspitali, where the majority of patients now receive antiemetic prophylaxis, and the use of total intravenous anaesthesia is the dominant mode for maintenance of anaesthesia. The aim of this study was to assess the incidence of postoperative nausea and vomiting (PONV) in a prospective way, the use of PONV prophylaxis, and clinical risk factors associated with PONV during this era. A prospective cohort study using a convenience sample of 438 patients ≥18 years old admitted to the postoperative care unit (PACU) after elective or emergency operations in May-July 2022 at Landspitali University Hospital in Iceland. Patients answered questionnaires in the PACU and 24 h after discharge from PACU. The incidence of self-reported moderate/severe nausea (5/10 or higher on NRS) in PACU was 4% and 3% on postoperative day 1. A total of 91% of delivered anaesthetics were with intravenous medications only, and 82% of patients received at least one prophylactic medication for PONV. When asked to rate the worst nausea experienced, this was described as moderate/severe by 7% in PACU and 17% on postoperative day 1. Risk factors associated with PONV were female gender (OR 1.90, 95% CI 1.04-3.53) and a history of motion sickness or PONV (2.74, 1.51-4.94), but increasing age was protective (0.83 per decade, 0.71-0.98). Despite a more liberal administration of antiemetics, patients with more risk factors per Apfel PONV risk classification had a higher incidence of PONV. The incidence of PONV is generally low in this diverse surgical population where anaesthesia is mostly maintained with total intravenous anaesthesia and PONV prophylaxis is common. PONV remains a predictable complication following anaesthesia, suggesting further improvement in its prevention is possible.