Original Article

The impact of the Apfel scoring system for prophylaxis of

post‑operative nausea and vomiting: A randomized controlled
trial

Shastri H Avinash, Handattu Mahabaleswara Krishna

Department of Anesthesiology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Abstract
Background and Aims: Post‑operative nausea and vomiting (PONV) is common, undesirable, and stressful following surgery.
By focusing attention and resources on those groups of patients most likely to develop PONV, the quality of care provided to
the patients can be improved. The primary objective was to compare the incidence of PONV after implementation of the Apfel
scoring system with the control group receiving prophylaxis for every surgery. The secondary objective was to identify the effect
on the patient’s expenditure/savings with respect to management of PONV.
Material and Methods: This prospective randomized controlled double‑blinded study enrolled 70 patients undergoing
surgeries under general anesthesia. Patients were randomized to group A (control group – all received PONV prophylaxis) and
group B (Apfel stratification performed for PONV prophylaxis). Based on the Apfel system, the risk of PONV was classified as
the grades low, moderate, and high risk. Patients at moderate and high risk received PONV prophylaxis in group B. Patients
were monitored for PONV during 24 h after surgery and rescue medication given as required. The effect of implementing Apfel
risk stratification on the incidence of PONV (primary outcome measure) and on patient expenditure was compared.
Results: Compared to administering prophylaxis for all patients, the incidence of PONV [group A‑5 patients (14.3%)] did
not increase (P = 0.428) after implementing the Apfel scoring system [group B‑2 patients (5.7%)]. The number of patients
spending on prophylaxis for PONV in group A [35 (100%)] was higher than that in group B [17 (48%)], without increasing
expenditure on PONV treatment.
Conclusion: Withholding prophylaxis on the basis of the Apfel scoring system did not increase the incidence of PONV
compared to providing prophylaxis for all the patients. The overall cost of prevention and treatment of PONV is less when the
Apfel scoring system is used.

Keywords: Apfels` scoring system, post‑operative nausea and vomiting, prophylaxis for PONV

Introduction and pain.[1] It could result in many adverse events such as

discomfort, dehiscence of sutures, gastric content aspiration,
Post‑operative nausea and vomiting (PONV) is undesirable, and esophageal rupture and result in delayed discharge from
stressful, and detrimental, especially in the first 24 h of the the hospital.[2] The incidence may be as high as 20–30%.[3]
post‑operative period. PONV pathogenesis is multi‑factorial
and may be initiated by various peri‑operative stimuli, such as The intent in providing prophylaxis for PONV is to mitigate
opioids, volatile anesthetics, anxiety, adverse drug reactions, the possibility of PONV, thereby improving the quality of

Address for correspondence: Prof. Handattu Mahabaleswara Krishna,

Department of Anesthesiology, Kasturba Medical College, Manipal, This is an open access journal, and articles are distributed under the
Manipal Academy of Higher Education, Manipal, Karnataka, India. terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike
E‑mail: [email protected] 4.0 License, which allows others to remix, tweak, and build upon the
work non‑commercially, as long as appropriate credit is given and
Access this article online the new creations are licensed under the identical terms.
Quick Response Code:
Website: For reprints contact: [email protected]
https://journals.lww.com/joacp
How to cite this article: Avinash SH, Krishna HM. The impact of the Apfel
scoring system for prophylaxis of post‑operative nausea and vomiting:
A randomized controlled trial. J Anaesthesiol Clin Pharmacol 2023;39:463-7.
DOI:
10.4103/joacp.joacp_553_21 Submitted: 23‑Dec‑2021 Revised: 26-Mar-2022
Accepted: 17‑Apr‑2022 Published: 02-Jun-2023

© 2023 Journal of Anaesthesiology Clinical Pharmacology | Published by Wolters Kluwer - Medknow 463
 Avinash and Krishna: Impact of Apfel scoring system on PONV

care. The practice of PONV prophylaxis for every patient On the day of surgery, adequate fasting was confirmed and
undergoing surgery under general anesthesia is seen in many patients were shifted into the operating room. Consenting
institutions.[4] This practice has been questioned because adults were randomly allotted to receive routine PONV
not all patients undergoing surgery under general anesthesia prophylaxis (group A) or PONV prophylaxis (group B) as
develop PONV.[5] Scoring systems to predict PONV and per the risk by opening the sealed envelope containing the group
identify patients at increased risk for PONV are described allocation for the patient based on the computer‑generated
in the literature.[4] Such scoring systems or risk stratification random number table. In GROUP A, PONV prophylaxis
systems as introduced by CC Apfel et al.[6,7] (Germany) and was provided to all patients with intravenous (IV) ondansetron
Koivuranta M et al.[8] (Finland) are used to provide PONV 0.1 mg/Kg, rounded off to the nearest unit decimal,
prophylaxis to only those patients at high risk for PONV.[4] administered about 30 min prior to expected completion of the
surgery. In GROUP B, PONV prophylaxis was provided
This study evaluates the effect of applying risk stratification to the patients with IV ondansetron 0.1 mg/Kg, rounded off
of the Apfel scoring system on the incidence of PONV and to nearest unit decimal, administered about 30 min prior to
its impact on patient expenditure/savings. expected completion of the surgery on the basis of the Apfel
score [i.e., only the moderate (score 2) and high (score 3,
The primary objective was to compare the incidence of 4) risk patients received prophylaxis, whereas the low risk
PONV after implementation of the Apfel scoring system with patients (score 0, 1) did not receive prophylaxis]. The group
the control group receiving prophylaxis for every surgery. The allocated was not revealed to the patient, and the specially
secondary objective was to identify the impact of the scoring instructed nurse or anesthesiology resident assessed the number
system on the patient’s expenditure/savings with respect to of episodes of nausea and vomiting in the post‑anesthetic care
management of PONV. unit for 24 h after surgery, thus ensuring blinding.

Material and Methods The standard monitors of pulse oximetry, non‑invasive

blood pressure, and five‑electrode electrocardiography
This prospective, randomized controlled double‑blinded trial were attached to the patient, and baseline values were
was conducted after obtaining approval from Institutional documented. Suitable IV access was secured. A standard
ethics committee and registration at the Clinical Trial Registry general anesthesia technique with tracheal intubation
of India (CTRI/2019/01/017007). The study was conducted was followed by the concerned anesthesiologist in all the
at a tertiary care referral and teaching hospital over a period of patients. Pre‑oxygenation was performed for 3 minutes
2 years. Conducted over a span of 2 years, the study included with 100% oxygen. Anesthesia was induced with IV
patients of either gender, aged between 18 and 65 years, fentanyl and IV propofol. The ease of manual ventilation
belonging to the American Society of Anesthesiologists was confirmed, and neuro‑muscular blockade was achieved
physical status I and II, scheduled for various elective surgeries using IV vecuronium/IV atracurium and ventilated with 2%
under general anesthesia with tracheal intubation. Patients isoflurane/sevoflurane in 100% oxygen. After 3 minutes of
whose trachea was not extubated after surgery, with known giving the muscle relaxant, intubation was performed with
allergy to ondansetron and in whom the metoclopramide suitable‑sized tracheal tubes. Anesthesia and analgesia were
drug was used for aspiration prophylaxis were excluded from maintained according to the discretion of the concerned
the study. anesthesiologist with fentanyl/morphine intravenously and/
or epidurally (intra‑operative/post‑operative analgesia) along
Pre‑operative evaluation was performed by the anesthesiologist with non‑steroidal anti‑inflammatory drugs (NSAID) or
on the day prior to surgery, and written informed consent paracetamol. Anesthesia was maintained with nitrous oxide
was obtained from the participants. Standard guidelines for or air, oxygen, isoflurane/sevoflurane, and intermittent boluses
fasting and pre‑medication were advised as per the concerned of vecuronium/atracurium. Use of dexamethasone in the
anesthesiologist. During the pre‑anesthetic checkup, patients’ intra‑operative period (as for empirical anti‑inflammatory/
risk for PONV was assessed as per the Apfel scoring system. anti‑edema measure) and the use of nasogastric tubes in the
Accordingly, the risk factors stated by the scoring system, peri‑operative period were noted. The anesthetic technique
namely, female gender, non‑smoking status, previous history used in every patient was recorded, and the requirement of
of PONV, and post‑operative use of opioids were awarded post‑operative use of opioids was decided pre‑operatively
with a score of 1, with the total score ranging from 0 to 4. The based on the type of surgery. At the end of the surgery, all
risk of PONV was classified as the grades low (scores 0, 1), inhalational anesthetic agents were tapered. Once the patient
moderate (score2), and high risk (scores 3, 4). began to have some spontaneous respiratory efforts, reversal of

464 Journal of Anaesthesiology Clinical Pharmacology | Volume 39 | Issue 3 | July‑September 2023

 Avinash and Krishna: Impact of Apfel scoring system on PONV

neuro‑muscular blockade was performed using a combination mass index) were compared with the Student t‑test. Gender
of IV neostigmine and glycopyrrolate based on the weight distribution and distribution of Apfel scores in both the groups
of the patient and extubation was performed. PONV was were compared with the Chi‑square test. The incidence of
monitored for 24 h as episodes complained by the patient or PONV was compared with the Fisher exact test. A P value
observed by the nurse. The rescue antiemetic that was used less than 0.05 was considered significant.
in the case of PONV was IV metoclopramide 10 mg. If the
PONV episodes persisted despite this rescue medication, Result
then IV dexamethasone 0.2 mg/kg was administered. The
requirement for rescue medications was recorded. There were Figure 1 shows the consort flow chart of the study. Patient
two observers in the study. Observer 1 was the anesthesiology characteristics are given in Table 1. Table 2 shows the Apfel
resident who performed the pre‑operative evaluation, enrolled scores of the patients from the two groups. Although patients
the participants based on inclusion and exclusion criteria, in group A did not receive PONV prophylaxis based on Apfel
obtained written informed consent, and was not blinded to scores, all received the prophylaxis; Apfel scoring was performed
the patient’s allocated group. Observer 2 was the specially to see if the risk for PONV was comparable between the two
instructed nurse or anesthesiology resident who was blinded groups. The types of surgeries (including the laparoscopic
to the group allocation and assessed the number of episodes surgeries) undergone by the patients of both the groups were
of nausea and vomiting in the post‑anesthetic care unit for analyzed and found to be comparable between the two groups.
24 h after surgery. The comparison was performed because the Apfel scoring
system does not take into account the type of surgery as a risk
The primary outcome measure was the incidence of PONV. factor for identifying patients at high risk for PONV.
Vomiting or retching, as reported by the patient or observed
by the nurse, was considered as an emetic episode. This was Table 3 gives the Apfel scores of patients who had PONV.
assessed in the post‑operative period for the first 24 hours. In group B, patients who were stratified to have a low risk
The secondary outcome measures were the cost for prophylaxis for PONV (and hence did not receive prophylaxis) did not
and treatment of PONV. This was calculated by data have PONV.
from the actual cost of ondansetron, metoclopramide, and
dexamethasone when used or there was a potential use for The incidence of PONV during the first 24 h is given in
prophylaxis. Table 4. There was no significant difference in the incidence
of PONV because of implementation of the Apfel scoring
Sample size was calculated using the formula for comparison of system in group B when compared with the incidence of
two proportions, n = (Zα/2 + Zb) 2 * (p1(1‑p1)+p2 (1‑p2))/ PONV in group A. The incidence of PONV does not
(p1‑p2)2, where, n = size of the group, p1 = 0.3 (assuming 30% increase after application of the Apfel scoring system. The
incidence in group A), p2 = 0.4 (incidence of 40% in group B), opioid consumption was compared between the two groups
p1‑p2 = clinically meaningful difference in proportions of the
outcome, β = power of study, Zα/2 = two‑tailed significance ANALYSED FOR
level (1.96 for α at 5% significance), and Zb = 0.84 for ELIGIBILITY (n = 75)
80% power of study. Sample size was estimated based on Excluded (n = 5)
the comparison of incidence of PONV among group A and Surgery cancelled (n = 3)
Declined to participate (n = 2)
group B. Assuming 30% incidence of PONV in group A
and considering an increase in incidence of PONV by 10% in RANDOMIZED (n = 70)
group B because of curtailed PONV prophylaxis to low risk
patients in group B, as significant, the sample size required was
35 in each group with 80% power and 5% level of significance.
GROUP A GROUP B
The incidence was based on the audit of PONV incidence ALLOCATED n = 35 ALLOCATED n = 35
in the institution, which matched with the incidence quoted
in the literature.[3]
ANALYSIS ANALYSIS
n = 35 n = 35
Data were analyzed using SPSS version 16 for Windows
in consultation with the department of medical statistics.
Numerical and categorical data were analyzed using the FOLLOW UP FOLLOW UP
n = 35
Student t‑test, Chi‑square test, or Fisher exact test as n = 35

appropriate. Patient characteristics (age, body weight, body Figure 1: CONSORT flow chart of the study

Journal of Anaesthesiology Clinical Pharmacology | Volume 39 | Issue 3 | July‑September 2023 465

 Avinash and Krishna: Impact of Apfel scoring system on PONV

Table 1: Patient characteristics receive the prophylaxis for PONV from group B as they
Group A Group B P belonged to low risk group based on the Apfel scoring system,
Age (years) 35.9 (12.2) 40.1 (11.7) 0.153 there was no significant increase in the incidence of PONV in
Height (centimeters) 166.8 (8.0) 165.8 (8.6) 0.627 group B when compared to the incidence in group A.
Weight (kilograms) 64.8 (12.1) 63.8 (12.2) 0.724
Body Mass Index (kg/m2) 23.2 (3.6) 23.1 (3.1) 0.850 Since the number of episodes of PONV in the first 24 h was
Gender (Male/Female) 17/20 18/15 0.473 comparable the cost involved in treatment of PONV (Rs 5 per
Data are mean (standard deviation) for age, height, weight, and body mass
index; Student t‑test used. Data are absolute numbers for gender distribution;
ampoule of metoclopramide) was also comparable between
Chi‑square test used the two groups.

Table 2: Apfel score of patients in both groups Discussion

Apfel Score Group A n (%) Group B n (%) P*
0 4 (11.4) 7 (20.0) In this study, we determined the impact of implementing
1 8 (22.9) 11 (31.4) 0.172 the Apfel scoring system for prophylaxis of PONV on the
2 18 (51.4) 9 (25.7) incidence of PONV. We also evaluated the impact of the
3 5 (14.3) 6 (17.1) Apfel scoring system on the expenditure/saving pertaining to
4 0 (0.0) 2 (5.7)
the prophylaxis and treatment of PONV.
Total 35 (100) 35 (100)
*Chi‑square test
In total, about six scoring systems have been listed in the
literature to anticipate the occurrence of PONV.[6] The
Table 3: Patients who had PONV and their Apfel score scoring systems available to predict the incidence of PONV
from both the groups
were compared in a clinical study which found that the Apfel
Apfel score Group A (n) Group B (n)
0 1 0
and Koivuranta scoring systems are appropriate instruments
1 1 0 to provide a rational and economical antiemetic prophylaxis.[6]
2 2 1
3 1 1 Hence, we picked up the scoring system described
4 0 0 by Apfel CC et al.[6,7] to determine its impact in predicting
Total 5 2 the incidence of PONV and on the expenditure/saving if
implemented in our daily clinical practice.
Table 4: Incidence of post‑operative nausea and vomiting
in 24 h This study shows that the Apfel scoring system is effective in
Episodes of PONV in 24 hrs Group A n (%) Group B n (%)
identifying the high risk groups for the occurrence of PONV.
Yes 5 (14.3) 2 (5.7) Even though about 51.4% participants of group B did not
No 30 (85.7) 33 (94.3) receive prophylaxis for PONV based on their Apfel score,
Total 35 (100) 35 (100) this did not result in an increase in the incidence of PONV
Fisher’s Exact test; P=0.428 when compared to group A. This prevents unnecessary
exposure of the low risk group of patients for prophylaxis
and found to be comparable. None of the patients received of PONV.
dexamethasone intra‑operatively nor had nasogastric tubes.
All anesthetics included the air–oxygen mixture, and nitrous The simplified scoring system demonstrated by Apfel et al.[7]
oxide was not used. All patients who had PONV were treated in the year of 1998 showed that the low risk group of patients
with the rescue medication IV metoclopramide 10 mg. No with an Apfel score of 0 or 1 could also have a likelihood
patient had to be given IV dexamethasone because of persistent for the occurrence of PONV at an incidence of 10% and
PONV despite treatment with metoclopramide. 21%, respectively. This result when compared with our study
showed that out of the 51.4% low risk group participants who
Although all the 35 patients belonging to group A spent did not receive any prophylaxis against PONV, only 5.7%
on the ondansetron ampoules for PONV prophylaxis, only participants had PONV in the 24 h post‑operative period.
17 patients from group B had to spend on the ondansetron Thereby, our study result was comparable to their findings.
ampoule because of implementation of Apfel’s risk stratification.
This translates to additional expenditure of Rs 24 per head The Apfel scoring system effectively reduces the expenditure
in group A, whereas only 17 patients in group B spent this in the context of prophylaxis for PONV without causing an
amount. It is noteworthy that although 18 patients did not increase in the further treatment of PONV. More than half

466 Journal of Anaesthesiology Clinical Pharmacology | Volume 39 | Issue 3 | July‑September 2023

 Avinash and Krishna: Impact of Apfel scoring system on PONV

of the participants of group B (51.4%) did not spend for Conclusion

the prophylaxis of PONV. Only two participants out of the
18 participants who did not receive prophylaxis in group B The incidence of PONV does not increase following the
had PONV as against five participants in group A who implementation of the Apfel scoring system compared to
had to spend on the treatment of PONV despite receiving providing prophylaxis for all the patients. Also, the scoring
the prophylaxis. The extent of saving depends on the actual system prevents the unnecessary expenditure on prophylaxis
cost of ondansetron and metoclopramide, which varies from of PONV in the low risk group without increasing the
country to country. expenditure on treatment of PONV. Hence, implementing
the Apfel scoring system is an effective approach to anticipate
Sebastian Pierre and co‑workers compared the Apfel PONV and to identify patients in whom PONV prophylaxis
scoring system with the scoring system described is warranted.
by Sinclair et al.[9] (which considers the type and duration
of the surgery as additional risk factors along with the risk Financial support and sponsorship
factors described by Apfel et al.[6,7]). In this study, patients Nil.
belonged to ASA 1 to 3 and underwent different types
of surgeries under general anesthesia with endotracheal Conflicts of interest
intubation. They found that the scoring system described by There are no conflicts of interest.
Apfel et al. was better than the scoring system described by
Sinclair et al.,[9] even though the scoring system of Sinclair References
et al. considered additional important risk factors for developing
PONV.[10] Therefore, despite addition of risk factors in other 1. Palazzo MG, Strunin L. Anaesthesia and emesis. I: Etiology. Can
risk stratification systems for PONV, the Apfel system Anaesth Soc J 1984;31:178–87.
2. Shaikh S, Nagarekha D, Hegade G, Marutheesh M. Postoperative
still remains one of the widely used, simple, and validated nausea and vomiting: A simple yet complex problem. Anesth Essays
methods. In a recent validation study, the Apfel scoring system Res 2016;10:388–96.
was found to have a favorable sensitivity and specificity in 3. Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA,
identifying the incidence of PONV and in customizing the et al. Consensus guidelines for the management of postoperative
nausea and vomiting: Anesth Analg 2014;118:85–113.
antiemetic strategy.[11] 4. van den Bosch JE, Kalkman CJ, Vergouwe Y, Van Klei WA,
Bonsel GJ, Grobbee DE, et al. Assessing the applicability of
The presence or absence of multiple factors that could have scoring systems for predicting postoperative nausea and vomiting.
influenced the incidence of PONV (apart from the patient Anaesthesia 2005;60:323–31.
5. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, et al.
characteristics and the type of surgery which are analyzed
Consensus guidelines for managing postoperative nausea and
in the results) was sought for post‑hoc after the study. This vomiting. Anesth Analg 2003;97:62–71.
included the use of nasogastric tubes, nitrous oxide, duration 6. Apfel CC, Kranke P, Eberhart LHJ, Roos A, Roewer N. Comparison
of surgery, opioid consumption in the intra‑operative period, of predictive models for postoperative nausea and vomiting. Br J
Anaesth 2002;88:234–40.
any use of intra‑operative steroids, and post‑operative feeding
7. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified
patterns. It was found that none of these confounded the risk score for predicting postoperative nausea and vomiting:
results as they were uniformly distributed between the two Conclusions from cross‑validations between two centers.
groups and comparable. Anesthesiology 1999;91:693.
8. Koivuranta M, Laara E, Snare L, Alahuhta S. Asurvey of
postoperative nausea and vomiting. Anaesthesia 1997;52:443-9.
There were some limitations in this study. Multiple factors 9. Sinclair DR, Chung F, Mezei G. Can postoperative nausea and
influencing the incidence of PONV were analyzed post‑hoc. vomiting be predicted? Anesthesiology 1999;91:109-18.
These could have been standardized in both the groups in 10. Pierre S, Benais H, Pouymayou J. Apfel’s simplified score may
the beginning to avoid their confounding effects. Similarly, favourably predict the risk of postoperative nausea and vomiting.
Can J Anaesth 2002;49:237–42.
the study was not powered sufficiently to interpret whether 11. Sherif L, Hegde R, Mariswami M, Ollapally A. Validation of the
adverse effects of ondansetron were avoided by implementation Apfel scoring system for identification of high‑risk patients for
of Apfel scoring. PONV. Karnataka Anaesth J 2015;1:115–7.

Journal of Anaesthesiology Clinical Pharmacology | Volume 39 | Issue 3 | July‑September 2023 467