What is the most common cause of PONV? An Expert Guide

September 29, 2025 •

4 min read

Affecting up to 80% of high-risk patients, postoperative nausea and vomiting (PONV) is a frequent and distressing complication following surgery. While many factors contribute, a specific aspect of anesthesia is recognized as the single most common cause of PONV.

Quick Summary

The most common cause is the use of general anesthesia, specifically volatile inhalational agents like sevoflurane or desflurane, combined with other risk factors. These anesthetic agents, along with opioid use, significantly increase the risk for postoperative nausea and vomiting. Understanding these factors is key to effective prevention.

Key Points

Anesthesia is the main trigger: General anesthesia, particularly volatile agents like sevoflurane, is the most common cause, especially in the immediate post-operative hours.
Risk is multifactorial: The overall risk of PONV is influenced by a combination of factors related to the patient, the surgery, and the anesthetic technique used.
Opioids increase risk: The use of opioids for postoperative pain relief is a significant cause of PONV, particularly in the later recovery phase.
Propofol is protective: Utilizing propofol-based total intravenous anesthesia (TIVA) instead of volatile agents can help reduce the incidence of PONV.
Females are at higher risk: Female patients are significantly more susceptible to PONV due to hormonal factors.
Prophylaxis is key: A multimodal approach combining different antiemetics and minimizing emetogenic factors is the most effective way to prevent PONV.

Understanding PONV: A Multifactorial Issue

Postoperative nausea and vomiting (PONV) refers to the experience of nausea and/or vomiting in the first 24 to 48 hours following a surgical procedure. While it is rarely life-threatening, it can be a significant source of patient discomfort, dissatisfaction, and in some cases, lead to more severe complications such as dehydration, wound dehiscence, or delayed hospital discharge. The development of PONV is not due to a single factor but is a complex interaction of patient, surgical, and anesthetic-related variables.

The Primary Culprit: Anesthetic Agents

While a definitive single cause is hard to isolate due to the multi-faceted nature of the condition, medical consensus identifies general anesthesia as the most common contributing factor, especially the use of volatile inhalational agents. Volatile anesthetics, such as sevoflurane and desflurane, are known to be emetogenic, particularly in the initial recovery period (0–2 hours post-surgery). The risk is dose-dependent, meaning higher concentrations and longer durations of exposure increase the likelihood of PONV.

The Role of Opioids

Another major contributor to PONV, especially later in the recovery period, is the use of opioids for pain management. Opioids stimulate receptors in the chemoreceptor trigger zone (CTZ) of the brain, a region responsible for inducing the vomiting reflex. Postoperative opioid use is consistently identified as a key risk factor, particularly when administered at higher doses. Reducing opioid use, often through multimodal pain management strategies, can significantly lower the risk of PONV.

Propofol: An Antiemetic Solution

In contrast to volatile anesthetics, the intravenous anesthetic propofol has antiemetic properties. Total intravenous anesthesia (TIVA) using propofol, rather than volatile agents, is a highly effective strategy for preventing PONV, particularly in high-risk patients. This technique, however, is not always suitable for every patient or procedure.

Significant Patient-Related Risk Factors

Beyond the anesthetic, certain patient characteristics predispose individuals to a higher risk of PONV. Recognizing these factors allows clinicians to tailor a prevention strategy and utilize prophylactic antiemetics effectively.

Female Sex: Women are significantly more prone to PONV than men, with some studies showing a two- to four-fold increased risk. Hormonal influences are thought to play a role.
History of PONV or Motion Sickness: A personal or family history of motion sickness or previous PONV is a powerful predictor for future episodes. This indicates a more sensitive vestibular or central nervous system.
Nonsmoking Status: Intriguingly, nonsmokers are at a higher risk for PONV compared to smokers. One theory suggests that smoking induces certain enzymes that break down emetogenic substances, offering a protective effect.
Age: Younger adults and older children tend to have a higher incidence of PONV compared to infants and older adults.

Surgical and Procedural Risk Factors

Certain surgical procedures are also independently associated with a higher incidence of PONV due to the location or nature of the surgery. These include:

Laparoscopic Surgery: These minimally invasive abdominal procedures can increase PONV risk.
Gynecological Procedures: Surgeries involving the female reproductive system are frequently associated with PONV.
Intracranial Surgery: Neurosurgeries carry a high risk, possibly due to direct stimulation of the brain's vomiting centers.
Ear, Nose, and Throat (ENT) Surgery: Particularly surgeries involving the middle ear, as they can affect the vestibular system.
Longer Surgery Duration: The longer the procedure, the greater the exposure to anesthetic agents and potential for other triggering factors.

Comparing PONV Risk Factors

To help visualize the interplay of risk factors, here is a comparison of low and high-risk scenarios.


Feature	Low Risk Scenario	High Risk Scenario
Anesthesia Type	Total intravenous anesthesia (TIVA) with Propofol	General anesthesia with volatile agents
Opioid Use	Minimal to no postoperative opioid use	High dose or continuous opioid administration
Patient History	No history of motion sickness or previous PONV	History of motion sickness or previous PONV
Smoking Status	Smoker	Nonsmoker
Gender	Male	Female
Surgery Duration	Short duration (e.g., <30 minutes)	Long duration (e.g., >60 minutes)
Surgical Procedure	Low-risk surgery	Gynecological, abdominal, or ENT surgery

Multimodal Approach to Prevention

Given the complexity of PONV, a multifaceted or multimodal approach is the most effective prevention strategy. This involves combining pharmacological and non-pharmacological interventions to reduce the overall risk. The 2020 American Society of Anesthesiologists (ASA) guidelines provide evidence-based recommendations for PONV management, emphasizing a tailored approach based on individual risk factors. You can find more information about these guidelines here: 2020 American Society of Anesthesiologists Practice Guidelines for the Management of Postoperative Nausea and Vomiting

Pharmacological strategies include administering a combination of antiemetic drugs that act on different neural receptors involved in the vomiting process, such as ondansetron (a serotonin antagonist) and dexamethasone (a corticosteroid). Non-pharmacological approaches may include proper hydration, regional anesthesia to minimize general anesthetic exposure, and aromatherapy.

Conclusion: Understanding the Full Picture

While general anesthesia, particularly volatile agents, is the most common cause of PONV, it's crucial to understand the full range of contributing factors. Patient-specific elements like a history of motion sickness, being female, and being a nonsmoker, coupled with surgical details like the procedure type and duration, all influence an individual's risk. By recognizing these risks, patients can have informed discussions with their healthcare providers to implement a preventative multimodal strategy, ensuring a more comfortable and smooth recovery from surgery.

Frequently Asked Questions

You can reduce your risk by discussing your personal risk factors with your anesthesiologist before surgery. Strategies can include using propofol-based anesthesia, limiting opioid use for pain, and receiving prophylactic antiemetic medication. Staying well-hydrated before and after surgery can also help.

Yes, but in an unexpected way. Nonsmokers are at a higher risk for PONV than smokers. This is likely due to chronic smoking inducing enzymes that help the body break down certain substances that can cause nausea.

The Apfel Simplified Risk Score is a clinical tool used to predict a patient's risk of developing PONV based on four key factors: female gender, history of PONV or motion sickness, nonsmoking status, and postoperative opioid use. A higher score indicates a greater risk.

TIVA is an anesthetic technique where a patient receives their anesthesia solely through intravenous medication, such as propofol, rather than a combination of IV drugs and inhalational gases. TIVA is often used to minimize the risk of PONV, as volatile gases are a major cause.

Yes, several surgical types are associated with a higher risk of PONV, including laparoscopic, gynecological, intracranial, and ear, nose, and throat (ENT) procedures.

Dehydration can contribute to the risk and severity of PONV. Maintaining adequate hydration, particularly with intravenous fluids during surgery, is part of a multimodal approach to prevention.

Nausea is the unpleasant, subjective feeling of needing to vomit. Vomiting is the active, forceful expulsion of stomach contents. While they are often linked, some patients may experience one without the other, and different risk factors can influence each separately.

PONV can last up to 48 hours after surgery, although it is most common in the first few hours post-procedure. The duration and severity can vary greatly depending on the individual's risk factors and the specific anesthetic and surgical factors involved.