A patient with 4/4 Apfel risk factors for PONV undergoes elective laparoscopic hysterectomy. Which prophylactic strategy is recommended by SAMBA/PONV guidelines?

• A Single antiemetic (ondansetron 4 mg IV) given at end of surgery
• B No prophylaxis — treat only if PONV occurs in PACU
• C Scopolamine patch alone as it provides 72-hour coverage
• D Multimodal prophylaxis: TIVA with propofol + two to three antiemetics from different drug classes ✓

Explanation

For high-risk patients (Apfel score 3–4), current PONV guidelines (Consensus guidelines for managing PONV — SAMBA/SOAP) recommend multimodal prophylaxis combining baseline risk reduction (TIVA with propofol instead of volatile agents, avoiding N2O, reducing opioids, adequate hydration) plus two or three antiemetics from different classes (e.g. ondansetron + dexamethasone + droperidol/scopolamine). Each antiemetic reduces relative PONV risk by 25–30%; combining agents with different mechanisms gives additive benefit without proportional side-effect increase.

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

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