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Apfel Score for Postoperative Nausea and Vomiting (PONV)

The simplified Apfel score counts four PONV risk factors (female sex, non-smoker, history of PONV or motion sickness, postoperative opioids). 0, 1, 2, 3 and 4 factors predict PONV risks of about 10%, 21%, 39%, 61% and 79%; prophylaxis is advised with ≥2 factors.

Female sex (yes/no, +1)
Non-smoker (yes/no, +1)
History of PONV or motion sickness (yes/no, +1)
Postoperative opioids planned (yes/no, +1)

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Interpretation

Result	Meaning
0	10%
1	21%
2	39%
3	61%
4	79%

Formula

One point each: female sex, non-smoker, history of PONV or motion sickness, planned postoperative opioids. Risk of PONV in 24 h: 0 = 10%, 1 = 21%, 2 = 39%, 3 = 61%, 4 = 79%.

Clinical pearls

Derived in adults having inhalational anaesthesia; children use the POVOC score instead.
Total IV anaesthesia with propofol and opioid-sparing analgesia reduce baseline risk; each prophylactic antiemetic lowers relative risk by about 25%.

Examples

apfel female nonsmoker with postop opioids ponv risk for a male smoker with motion sickness, no opioids apfel score woman, never smoker, prior ponv, pca planned

FAQ

What is a high Apfel score?

3 or 4 risk factors (61–79% PONV risk) is high risk and warrants multimodal prophylaxis; 2 factors (39%) is moderate.

What are the Apfel risk factors?

Female sex, non-smoking status, history of PONV or motion sickness, and use of postoperative opioids.

Evidence

Apfel CC et al. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91:693–700.

Surgery & Perioperative · Reviewed 2026-10-14 · Methodology