Apfel score (PONV)
Risk of postoperative nausea and vomiting in adults
Sources last checked: 2026-10-13
Apfel score (PONV)
Risk of postoperative nausea and vomiting in adults
PONV incidence ≈ 10 % in the derivation data.
Derived in adults under inhalational anaesthesia (Finnish and German centres). Not validated in children; paediatric scores such as POVOC/Eberhart exist for that group.
Interpretation
| 0 factors | PONV incidence ≈ 10 % in the derivation data. |
|---|---|
| 1 factor | PONV incidence ≈ 21 %. |
| 2 factors | PONV incidence ≈ 39 %. The authors suggested considering prophylaxis from two factors. |
| 3 factors | PONV incidence ≈ 61 %. |
| 4 factors | PONV incidence ≈ 79 %. |
What is the Apfel score (PONV)?
The simplified Apfel score predicts postoperative nausea and vomiting (PONV) in adults from four risk factors: female sex, non-smoking status, prior PONV or motion sickness, and expected postoperative opioids. Apfel and colleagues derived it in 1999 from Finnish and German cohorts under inhalational anaesthesia. Risk rises from about 10 % with no factors to about 79 % with all four.
When to use it
- Pre-anaesthetic assessment of adults undergoing general anaesthesia
- PONV risk stratification, to which the Fourth Consensus Guidelines (Gan 2020) link the extent of antiemetic prophylaxis
- Day-surgery planning, where PONV delays discharge
When not to use it
- Children — paediatric scores (e.g. POVOC) include different factors
- Postdischarge nausea after ambulatory surgery, which has its own model
How it is calculated
| Criterion | Points |
|---|---|
| Female sex | +1 |
| Non-smoker | +1 |
| History of PONV or motion sickness | +1 |
| Postoperative opioids expected | +1 |
Clinical pearls and limitations
- Derived in adults under inhalational anaesthesia (Finnish and German centres). Not validated in children; paediatric scores such as POVOC/Eberhart exist for that group.
- Each factor adds roughly 20 percentage points of risk.
- The Fourth Consensus Guidelines (Gan 2020) favour multimodal prophylaxis even for patients with one or two factors and describe total intravenous anaesthesia and opioid-sparing analgesia as reducing baseline risk.
- The score was built for inhalational anaesthesia; risk under TIVA is lower than the table suggests.
- "Postoperative opioids" means anticipated use after surgery, not intraoperative opioids.
Frequently asked questions
What are the four Apfel risk factors?
Female sex, non-smoker, history of PONV or motion sickness, and planned postoperative opioids.
What is the PONV risk with an Apfel score of 3?
About 61 % in the original derivation data.
Can the Apfel score be used in children?
No. It was derived in adults; paediatric scores such as POVOC are used for children.
Evidence and guidelines
- Primary source: Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting. Anesthesiology 1999;91(3):693-700 (incidences 10/21/39/61/79 % from the abstract).
- Gan TJ et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg 2020;131(2):411-448.
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