Postoperative nausea and vomiting: current concepts, management strategies, and future perspectives

Postoperative nausea and vomiting (PONV) remains one of the most common and distressing adverse events after anesthesia and surgery, with important effects on patient comfort, recovery quality, discharge readiness, and healthcare resource use. Although advances in anesthetic techniques, antiemetic pharmacology, and enhanced recovery pathways have improved perioperative care, PONV continues to occur frequently because of its multifactorial pathophysiology and variable individual susceptibility. This narrative review provides a clinically oriented overview of current concepts in PONV, including epidemiology, clinical burden, neurochemical mechanisms, risk factors, prediction models, baseline risk reduction, pharmacological prophylaxis, rescue treatment, postdischarge care and future perspectives. PONV results from complex interactions among central and peripheral emetic pathways, including gastrointestinal vagal afferents, the chemoreceptor trigger zone, vestibular input, higher cortical and limbic modulation, and multiple neurotransmitter systems such as serotonin, dopamine, histamine, acetylcholine, substance P, and opioid-mediated signaling. Structured risk assessment, particularly using simplified prediction tools such as the Apfel score, remains essential for guiding individualized prophylaxis. Preventive strategies should combine reduction of modifiable perioperative risk factors with appropriate multimodal antiemetic therapy. Key interventions include minimizing exposure to volatile anesthetics and nitrous oxide when suitable, using opioid-sparing analgesia, optimizing hydration and fasting practices, and integrating regional or neuraxial techniques when appropriate. Pharmacological management relies on agents targeting different receptor systems, including 5-HT3 receptor antagonists, dopamine receptor antagonists, neurokinin-1 receptor antagonists, glucocorticoids, anticholinergics, and antihistamines. Future research should improve prediction accuracy, clarify optimal prophylactic combinations, strengthen guideline implementation, evaluate postdischarge symptoms, and explore artificial intelligence-assisted individualized prevention. A comprehensive, risk-based, and patient-centered approach remains central to reducing the burden of PONV.