Which antiemetic combination is recommended for prophylaxis in a high-risk PONV patient (Apfel score 4) undergoing elective laparoscopic hysterectomy under volatile anaesthesia?

• A Metoclopramide alone 10 mg IV
• B Scopolamine transdermal patch alone applied 2 hours postoperatively
• C Ondansetron 4 mg IV at induction only
• D Ondansetron 4 mg + dexamethasone 8 mg + droperidol 0.625–1.25 mg + TIVA with propofol ✓

Explanation

For Apfel score 4 (highest risk, ~79%), guidelines (Society for Ambulatory Anesthesia 2020 consensus) recommend multimodal combination prophylaxis: at least two to three antiemetics from different mechanistic classes, plus substitution of volatile anaesthesia with TIVA using propofol (itself antiemetic). Ondansetron (5-HT3 antagonist) + dexamethasone (mechanism involves reduced prostaglandins and serotonin release; anti-inflammatory) + droperidol (D2 antagonist) is a validated three-drug combination. Metoclopramide alone has insufficient efficacy. Transdermal scopolamine should be applied 4–12 hours before surgery, not after. Single-agent ondansetron is insufficient for score 4 patients.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.