Investigation of the attitudes and behaviors of anesthesiologists regarding the prophylaxis and treatment of postoperative nausea and vomiting

Abstract

Background:

Postoperative nausea and vomiting is a prevalent complication during the postoperative phase. Numerous factors affect postoperative nausea and vomiting, which can be categorized into patient-related, anesthesia-related, and surgery-related factors. The management of postoperative nausea and vomiting is multifaceted and consists of both prophylactic and therapeutic approaches.

Objectives:

This study aimed to investigate the attitudes and behaviors of anesthesiologists regarding the prophylaxis and treatment of postoperative nausea and vomiting, while also raising awareness of current practices and gaps in adherence to guideline-based management.

Methods:

This prospective observational study involved the online administration of a web-based questionnaire comprising 17 questions to physicians actively working in anesthesiology and reanimation clinics. The first five questions pertained to demographic data, while the remaining 12 questions assessed anesthesiologists’ attitudes and behaviors regarding the prophylaxis and treatment of postoperative nausea and vomiting.

Results:

The rate of missing to conduct postoperative nausea and vomiting risk assessments and not providing prophylaxis (n = 67) was 33.5%, whereas the rate of administering prophylaxis with a single agent to each patient without risk assessment (n = 85) was 42.5%. Among the anesthesiologists who participated in the study, the awareness rate regarding the prophylaxis and treatment of postoperative nausea and vomiting was found to be 90.0%.

Conclusions:

This study demonstrates that, in current clinical practice, postoperative nausea and vomiting risk assessment and prophylaxis remain an overlooked complication. A clear gap exists between awareness and evidence-based practice in postoperative nausea and vomiting management. Therefore, the most appropriate prophylaxis and treatment strategies should be identified on a patient-specific basis. These findings highlight the need for structured risk assessment and guideline-based prophylaxis strategies to optimize patient outcomes.

Keywords

nausea and vomiting postoperative anesthesia recovery period enhanced postsurgical recovery

Introduction

Postoperative nausea and vomiting (PONV) is one of the most frequently encountered adverse effects in the postoperative period. In the absence of prophylaxis, PONV is estimated to occur in ~30% of the general adult surgical population and in nearly 80% of high-risk cohorts. Beyond merely causing patient discomfort and dissatisfaction, refractory PONV is associated with prolonged stays in the post-anesthesia care unit, unanticipated hospital admissions, numerous medical complications, and increased healthcare costs.¹ A systematic review by Darvall et al. found that postoperative nausea occurred in 18%–45% of patients (mean 36%) and vomiting in 16%–25.5% (mean 25%).² PONV can lead to several complications, including dehydration, electrolyte imbalances, associated cardiac arrhythmias, aspiration of gastric contents, wound dehiscence, esophageal rupture, subcutaneous emphysema, and bilateral pneumothorax.³

Numerous factors affect PONV, which can be categorized into patient-related, anesthesia-related, and surgery-related factors.⁴ The management of PONV is multifaceted and consists of both prophylactic and therapeutic approaches. Among the patient-related risk factors identified by Apfel et al. are female gender, non-smoking status, postoperative opioid use, and a history of motion sickness. Apfel et al. developed a risk factor scale ranging from 0 to 4, in which having zero risk factors corresponded to a 10% likelihood of developing PONV, while each additional risk factor increased the predicted risk. According to this scale, the estimated risk of PONV is ~10%, 20%, 40%, 60%, or 80%, depending on the number of present risk factors.⁵

Although the use of PONV prophylaxis significantly predates Enhanced Recovery After Surgery (ERAS), the advent of ERAS has highlighted the importance of antiemetic prophylaxis in perioperative care and emphasized the truly multifactorial nature of postoperative gastrointestinal dysfunction.⁶ Strategies for minimizing PONV should ideally be identified during the preoperative period and incorporated into each patient’s anesthesia plan. The key components of intraoperative PONV reduction strategies include targeted drug selection, anesthesia management, and the implementation of techniques proven to minimize PONV.

The primary objective of this study was to evaluate anesthesiologists’ attitudes and behaviors regarding the prophylaxis and treatment of PONV. A secondary objective was to explore whether participation in the survey itself contributed to increased awareness of guideline-based PONV management.

Materials and methods

Following the approval of the Local Ethics Committee of Eskisehir Osmangazi University Faculty of Medicine (date/number: September 28, 2021/04), a web-based survey was conducted between October 2021 and March 2022.

The study was designed as a cross-sectional observational survey study in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, and the checklist is provided as Supplementary File.

The questionnaire consisted of 17 items. The first five items collected demographic data, while the remaining 12 addressed anesthesiologists’ knowledge, attitudes, and behaviors regarding the prophylaxis and treatment of PONV. Participation in the survey was voluntary, and informed consent was obtained from all participants prior to questionnaire completion.

A total of 247 anesthesiologists responded. Incomplete responses were defined as questionnaires with more than 20% of items left unanswered. Forty-seven participants met this criterion and were excluded, leaving 200 respondents for the final analysis. Participants were recruited through institutional mailing lists and professional anesthesiology associations. The response rate was 81%. Physicians actively working in anesthesiology and reanimation clinics in Turkey were eligible for inclusion. The final question of the survey explicitly asked respondents whether participating in the questionnaire increased their awareness regarding PONV prophylaxis. For this study, “awareness” was operationally defined as a self-reported increase in knowledge or sensitivity toward the importance of risk assessment and prophylaxis for PONV after completing the survey. This was assessed through the final survey question: “Did participating in this survey increase your awareness of PONV prophylaxis?” Responses to this item were used to quantify awareness.

The questionnaire was not subjected to formal validation or pilot testing, which we acknowledge as a limitation of the study.

Statistical analysis

All statistical analyses were performed using SPSS version 21.0 (IBM Corp., Armonk, NY, USA). A priori power analysis was performed at a 95% confidence interval, indicating that a minimum of 141 participants was required based on effect sizes reported in a relevant meta-analysis.

Descriptive statistics (frequency and percentage values) were calculated for categorical variables. Chi-square tests were used to assess associations between categorical variables. Graphical representations were created to illustrate key findings. Effect sizes, multivariable modeling, and corrections for multiple comparisons were not performed and are acknowledged as limitations of the present study.

Results

Survey questions were administered to anesthesiologists affiliated with professional associations in Turkey through an online platform. A total of 247 anesthesiologists initially participated in the survey. Of these, 47 were excluded because they left more than 20% of the questionnaire items unanswered. Consequently, only respondents who completed all items were included in the final analysis (n = 200). All included participants were actively working in anesthesiology and reanimation clinics.

An examination of the participants’ demographic data revealed that 43.5% were aged 36 years or older, 64.0% were female, and 45.5% were working as research assistant doctors. In addition, 44.5% had 5 years or less of anesthesia experience, and 47.5% were employed at a university hospital. An analysis of the departments where participants worked as consultant anesthesiologists in the operating room showed that 78.5% were affiliated with general surgery, 71.5% with otorhinolaryngology, and 71.5% with orthopedics and traumatology (Table 1).

Table 1.

Demographic characteristics, anesthesia experience, and PONV-related questions.

Variable/question	Response	n	%
Age (years)	⩽30	68	34.0
	31–35	45	22.5
	⩾36	87	43.5
	Minimum–maximum (mean ± SD)	25–73 (37.12 ± 9.70)
Gender	Female	128	64.0
Gender	Male	72	36.0
Position in current institution	Research assistant doctor	91	45.5
	Specialist doctor	80	40.0
	Assistant professor	7	3.5
	Associate professor	13	6.5
	Professor	9	4.5
Years of anesthesia experience (years)	<5	89	44.5
	5–10	42	21.0
	10–20	43	21.5
	>20	26	13.0
Current institution	University	95	47.5
	MoH Training and Research Hospital	48	24.0
	MoH/University Affiliated Hospital	14	7.0
	MoH State Hospital	28	14.0
	Private Hospital/Medical Center	15	7.5
How often do you encounter PONV?	Never	8	4.0
	Rarely (one to two times per month)	89	44.5
	Frequently (one to two times per week)	83	41.5
	Very frequently (daily)	20	10.0
Is PONV risk scoring used in your clinic?	Yes, for every patient	22	11.0
	Yes, only for major surgery	26	13.0
	No, not performed; prophylaxis not applied	67	33.5
	No, not performed; single-drug prophylaxis applied	85	42.5
Most decisive factor for prophylaxis	Apfel scoring	56	28.3
	Type of surgery	116	58.6
	Other	26	13.1
Do drug side effects influence your choice?	Yes	177	88.5
Do drug side effects influence your choice?	No	23	11.5
Have you encountered extrapyramidal side effects of metoclopramide?	Yes, do not prefer	34	17.0
	Yes, but use if no alternative	85	42.5
	No, never encountered; I use it	81	40.5
Did participating in this survey increase awareness?	Yes	180	90.0
For which types of surgery do you routinely apply PONV prophylaxis? (you may choose more than one)	No	20	10.0
	Bariatric surgery	117	58.5
	Laparoscopic surgeries	147	73.5
	Gynecological surgeries	90	45.0
	Cholecystectomies	118	59.0
	Middle ear surgeries	124	62.0
	Other	45	22.5

Academic definitions in Turkey: specialist doctor—physicians with 5 years of anesthesia and reanimation training; research assistant doctor—residents in anesthesia and reanimation after medical school; assistant professor—early-stage faculty member; associate professor—title obtained after sufficient publications and experience; professor—the highest academic title after 5 years as associate professor.

SD: standard deviation; MoH: Ministry of Health; PONV: postoperative nausea and vomiting.

Regarding the frequency of encountering PONV and the utilization of risk scoring systems, 44.5% of respondents reported rarely encountering PONV, while 42.5% indicated that their clinic did not implement a PONV risk scoring system but instead applied single-drug prophylaxis to all patients. The most decisive factor in PONV prophylaxis decisions was reported to be the type of surgery (e.g., gastrointestinal surgery, laparoscopy, and middle ear surgery) by 58.6% of respondents. Furthermore, 88.5% of the participants stated that the side effects of the antiemetic drug influenced their selection, and 42.5% reported using metoclopramide despite its extrapyramidal side effects when no alternative was available. The rate of practitioners who reported increased awareness of PONV prophylaxis after completing the survey was 90.0%. The analysis of surgical types in which PONV prophylaxis was routinely administered revealed that it was applied in 73.5% of laparoscopic surgeries, 62.0% of middle ear surgeries, and 59.0% of cholecystectomies (Table 1).

An evaluation of the implementation rates of ERAS protocols showed that 68.5% utilized a multimodal analgesia approach as part of a multidisciplinary strategy, 52.0% removed the nasogastric tube early unless deemed necessary by the surgical team, and 42.0% ensured early oral intake in the postoperative period. Regarding changes in anesthetic management for patients identified as high risk for PONV, 65.5% preferred multimodal analgesia, 62.5% opted for regional anesthesia, and 32.0% used nitrous oxide (Table 2). A statistically significant correlation (p < 0.05) exists between anesthesia experience and the choice for total intravenous anesthesia (TIVA) instead of inhalation anesthetics among patients classified as high risk for PONV. Fourteen point six percent of individuals with <5 years of experience, 11.9% with 5–10 years of experience, 32.6% with 10–20 years of experience, and 30.8% with more than 20 years of experience favor TIVA. In contrast to the American Society of Anesthesiologists (ASA) and the ERAS guidelines, which strongly emphasize risk stratification and multimodal prophylaxis, our findings demonstrate a tendency toward single-agent prophylaxis without formal risk assessment. This divergence highlights the need for improved adherence to evidence-based international recommendations in Turkey.

Table 2.

Implementation of ERAS protocols for PONV prophylaxis and multidisciplinary approaches applied in clinical practice.

(A) ERAS protocol components applied in the clinic
Protocol component	n	%
Ensuring that fasting duration is not prolonged	71	35.5
Allowing the consumption of carbohydrate-rich clear fluids up to 2 h before induction	25	12.5
Implementation of multimodal analgesia	137	68.5
Avoiding drain placement unless deemed necessary by the surgical team	18	9.0
Early removal of the nasogastric tube unless deemed necessary by the surgical team	104	52.0
(B) Anesthetic modifications for patients at high risk of PONV
Modification	n	%
I do not use nitrous oxide	64	32.0
I prefer total intravenous anesthesia	40	20.0
I prefer regional anesthesia	125	62.5
I prefer multimodal analgesia	131	65.5
I use opioid-free anesthesia	46	23.0

ERAS: Enhanced Recovery After Surgery; PONV: postoperative nausea and vomiting.

When asked about their preferred medication for the prophylaxis or treatment of PONV, 90.0% of the participants indicated 5HT3 antagonists (ondansetron and granisetron), 55.5% preferred corticosteroids (dexamethasone), and 43.0% selected dopamine antagonists (metoclopramide).

An analysis of combination therapy preferences in high-risk groups revealed that 62.0% preferred a combination of 5HT3 antagonists (ondansetron and granisetron) and corticosteroids (dexamethasone), 23.0% used a combination of 5HT3 antagonists (ondansetron and granisetron), corticosteroids (dexamethasone), and dopamine antagonists (metoclopramide), and 12.0% opted for corticosteroids (dexamethasone) combined with dopamine antagonists (metoclopramide; Figure 1 and Table 3).

Figure 1.

Preferences for treatment combinations, ranked from highest to lowest percentage. The most commonly reported combination was 5-HT3 antagonist (ondansetron and granisetron) plus corticosteroid (dexamethasone), followed by 5-HT3 antagonist plus corticosteroid plus dopamine antagonist (metoclopramide), corticosteroid plus dopamine antagonist, 5-HT3 antagonist plus corticosteroid plus antihistamine (dimenhydrinate), and acupuncture (PC6) combined with two medications with different mechanisms of action.

Table 3.

Medications most commonly preferred by anesthesiologists for the prophylaxis and treatment of PONV.

(A) Preferred medications
Medication	n	%
5HT3 antagonist (ondansetron and granisetron)	180	90.0
Corticosteroid (dexamethasone)	111	55.5
Dopamine antagonist (metoclopramide)	86	43.0
Antihistaminic (dimenhydrinate)	13	6.5
Acupuncture (PC6)	2	1.0
Other	6	3.0
(B) Preferred combination therapy for high-risk patients
Combination	n	%
Corticosteroid (dexamethasone) + dopamine antagonist (metoclopramide)	24	12.0
5HT3 antagonist (ondansetron and granisetron) + corticosteroid (dexamethasone)	124	62.0
5HT3 antagonist (ondansetron and granisetron) + corticosteroid (dexamethasone) + dopamine antagonist (metoclopramide)	46	23.0
5HT3 antagonist (ondansetron and granisetron) + corticosteroid (dexamethasone) + antihistaminic (dimenhydrinate)	18	9.0
Acupuncture (PC6) combined with two medications with different mechanisms of action	1	0.5
Other	8	4.0

PONV: postoperative nausea and vomiting.

The chi-square test results indicate a statistically significant relationship between the absence of nitrous oxide in the anesthetic approach and anesthesia experience in patients classified as high-risk groups concerning PONV (p < 0.05). Twenty-two point five percent of individuals with <5 years of experience, 33.3% of those with 5–10 years of experience, 41.9% of those with 10–20 years of experience, and 46.2% of individuals with more than 20 years of experience do not.

A statistically significant correlation exists between anesthesia experience and the choice for utilizing a dopamine antagonist (metoclopramide) for the prophylaxis or treatment of PONV (p < 0.05). Forty-two point seven percent of individuals with <5 years of experience, 52.4% of those with 5–10 years of experience, 51.2% of individuals with 10–20 years of experience, and 15.4% of those with more than 20 years of experience favor the dopamine antagonist metoclopramide.

A statistically significant correlation exists between anesthesia experience and the preference for antihistamines (dimenhydrinate) in the prophylaxis or treatment of PONV (p < 0.05). One point one percent of individuals with <5 years of experience; 9.5% of individuals with 5–10 years of experience; 9.3% of individuals with 10–20 years of experience; and 15.4% of individuals with more than 20 years of experience favor antihistamines (dimenhydrinate).

A statistically significant correlation exists between anesthesia experience and the impact of pharmacological side effects on the selection of PONV (p < 0.05). Ninety-one percent of individuals with <5 years of experience; 95.2% of individuals with 5–10 years of experience; 88.4% of individuals with 10–20 years of experience; and 69.2% of those with more than 20 years of experience are affected by the adverse effects of the medication they will utilize for PONV.

While 90% of participants reported that completing the survey increased their awareness regarding PONV prophylaxis, a large proportion (76%) still indicated that they do not routinely follow evidence-based prophylaxis protocols. This discrepancy suggests that although anesthesiologists may recognize the importance of guideline-based PONV prevention after reflection prompted by the survey, barriers such as institutional routines, drug availability, and personal preferences may prevent full adherence in daily practice.

Discussion

In this nationwide survey of anesthesiologists, three main findings emerged. First, routine use of validated PONV risk scoring systems was limited, with a considerable proportion of respondents relying on empirical or single-drug prophylaxis. Second, decision-making for prophylaxis was predominantly influenced by the type of surgery rather than standardized risk assessment tools. Third, although 90% of participants reported increased awareness of guideline-based PONV management after completing the survey, adherence to evidence-based practices in daily clinical care remained suboptimal.

These findings are consistent with previous studies demonstrating a gap between knowledge and practice in PONV prevention. For example, Darvall et al. highlighted variability in applying the Apfel risk score, and international consensus guidelines similarly emphasize the underuse of multimodal prophylaxis despite strong evidence of its effectiveness.² Our results, therefore, underscore the need for targeted educational initiatives and institutional support to translate awareness into practice.

According to the analysis results of our study, the incidence rates of PONV indicate that while the rate of participants who had never encountered PONV was as low as 4%, the rate of those who frequently encountered it (once or twice per week) was 41.5%. This finding underscores that PONV remains a significant issue in anesthesia practice. Numerous PONV risk assessment models have been published for many years; however, most of these models are complex. The Apfel and Koivuranta classification scores are widely used in clinical practice, and guidelines recommend the application of risk assessment and scoring for every patient undergoing surgical procedures, emphasizing their importance. Furthermore, ERAS protocols include provisions for PONV prophylaxis. Unlike the Apfel score, the Koivuranta score incorporates surgery duration exceeding 60 min as a risk factor, although the former is more commonly utilized in clinical settings.^7,8

This study revealed that, in clinical practice, a relatively high rate (42.5%) of practitioners did not perform PONV risk scoring but instead applied single-drug prophylaxis to all patients. In contrast, only 11% of the respondents reported using PONV risk assessment and scoring for every patient, highlighting that anesthesiologists did not frequently employ PONV risk assessment models. This finding suggests the need for increased attention to this issue. When evaluating the factors influencing the decision to implement PONV prophylaxis, 58.6% of the participants identified the type of surgery as the most decisive factor. This suggests that patient-related factors are not adequately considered, a finding consistent with the low rate (11%) of PONV risk scoring utilization.

Our findings were compared with international guidelines, including those of the (ASA/ERAS or other relevant organizations), and we observed notable areas of alignment as well as deviations. Possible reasons for the identified gaps may include differences in institutional protocols, availability of resources, and variations in individual clinical experience. The clinical implications of these gaps are significant, as they may affect the consistency of prophylaxis and treatment strategies, ultimately influencing patient outcomes. Addressing these issues through targeted education and the standardization of clinical practice could improve adherence to evidence-based guidelines.

Surgeons tend to place greater emphasis on pain management; however, the occurrence of PONV significantly affects patient experiences and postoperative rehabilitation exercises. Nonetheless, surgeons often overlook the prevention and treatment of PONV, possibly because it does not pose a direct threat to the patient’s life or is attributed to anesthetic reactions.

Dexamethasone is a long-acting glucocorticoid with potent anti-inflammatory properties and minimal corticoid effects, commonly used across various surgical fields to reduce PONV and postoperative pain. However, concerns regarding its side effects, including surgical site infections, delayed wound healing due to impaired blood glucose regulation, and gastrointestinal bleeding, remain significant in clinical practice. Nevertheless, studies have demonstrated that dexamethasone significantly reduces PONV within the first 24 h postoperatively, does not cause substantial changes in postoperative blood glucose levels, does not impair wound healing, and does not increase the risk of gastrointestinal bleeding.^9,10 There are also several first-line antiemetic drug classes, including dopamine (D2) antagonists (e.g., droperidol), serotonin (5HT3) antagonists (e.g., ondansetron), and corticosteroids (e.g., dexamethasone). A study involving 5199 patients demonstrated that when administered individually, these drug classes contributed to an ~25% relative risk reduction. Furthermore, the multimodal application of antiemetic drugs was found to further reduce the incidence of PONV.^11,12 ERAS protocols encompass a range of traditional practices, beginning with comprehensive preoperative patient education and extending to preoperative optimization, pre-anesthetic medication, perioperative fluid management, intraoperative hypothermia prevention, avoidance of drains and nasogastric tubes during surgery, early postoperative oral intake, and early mobilization.¹³

A multimodal approach to PONV prophylaxis should be considered for all patients and integrated into ERAS protocols. Patients with one or two risk factors should ideally receive dual-drug combination prophylaxis using first-line antiemetics. Patients undergoing colorectal surgery with two risk factors should receive two or three antiemetics. If nausea and/or vomiting persist despite prophylaxis, rescue therapy should be administered using drug classes different from those initially used, employing a multimodal approach.¹⁴ In our study, among participants’ combination therapy preferences for high-risk groups, the rate of those selecting 5HT3 antagonists (ondansetron and granisetron) and corticosteroids (dexamethasone) was 62.0%, while 23.0% opted for 5HT3 antagonists (ondansetron and granisetron), corticosteroids (dexamethasone), and dopamine antagonists (metoclopramide), and 12.0% preferred corticosteroids (dexamethasone) and dopamine antagonists (metoclopramide). It was observed that haloperidol and droperidol were not preferred by any of the practitioners who participated in the study.

Extrapyramidal reactions following metoclopramide administration have been reported in a small percentage of adult cases, with an incidence of 0.2%. These reactions include akathisia, characterized by restlessness and an urge for constant movement; trismus, involving decreased jaw opening due to masticatory muscle spasm; and acute dystonic reactions, causing muscle contractions leading to twisting movements, repetitive motions, or abnormal postures. Extrapyramidal reactions typically emerge within 24–48 h following treatment and resolve within 24 h after drug discontinuation.¹⁵ In our cohort, the rate of those preferring dopamine antagonists (metoclopramide) was 42.7% among those with <5 years of experience, 52.4% among those with 5–10 years of experience, 51.2% among those with 10–20 years of experience, and 15.4% among those with >20 years of experience. The lower preference for this drug among clinicians with over 20 years of experience may be associated with a higher likelihood of encountering its adverse effects.

Three primary mechanisms have been proposed to explain the contribution of nitrous oxide to increased PONV incidence.¹⁶ First, stimulation of the sympathetic nervous system leads to catecholamine release, causing changes in middle ear pressure that result in retraction of the round window membrane and subsequent vestibular system stimulation. Second, during mask ventilation, the exchange of nitrous oxide and nitrogen within the gastrointestinal system increases abdominal distension. Third, increased abdominal bloating due to gas exchange may contribute to PONV.¹⁷ In the current study, a statistically significant relationship was identified between anesthesia experience and the decision to avoid nitrous oxide in the anesthetic management of high-risk PONV cases. Among the participants, 22.5% of those with <5 years of experience, 33.3% of those with 5–10 years of experience, 41.9% of those with 10–20 years of experience, and 46.2% of those with >20 years of experience refrained from using nitrous oxide. This finding suggests that more experienced anesthesiologists are less likely to prefer nitrous oxide, an older anesthetic agent. Machine learning has recently drawn interest in creating PONV prediction models. Multiple models have been effectively created to predict PONV.^18–20

According to the results of our study, the incidence of PONV remains a significant problem in anesthesia practice. Although only 4% of participants reported never encountering PONV, 41.5% stated that they experienced it once or twice per week. This confirms that PONV continues to be a frequent and clinically important complication. Numerous PONV risk assessment models, such as the Apfel and Koivuranta scores, have been published and are widely used in international practice, with guidelines recommending their application to every surgical patient. Despite this, our findings revealed that only 11% of anesthesiologists consistently used a PONV risk score, while 42.5% administered prophylaxis to all patients without risk stratification. This discrepancy between high reported awareness (90%) and low implementation of risk-based strategies suggests that knowledge does not necessarily translate into evidence-based practice.

Several factors may underlie this gap. Institutional protocols often favor universal prophylaxis, which may be perceived as more practical and legally safer than selective approaches. Limited time in busy clinical environments and variability in available pharmacological agents may also explain why anesthesiologists bypass formal risk scoring. Furthermore, training programs and continuing education efforts may emphasize pain management over PONV prevention, leading to the underutilization of risk-based strategies. These findings are consistent with other international surveys, where guideline awareness is high but compliance remains suboptimal.

From a clinical perspective, this gap has important implications. PONV not only reduces patient comfort but also prolongs recovery, increases unplanned admissions, and contributes to complications such as dehydration, electrolyte disturbances, wound dehiscence, or aspiration. Improved adherence to guideline-recommended multimodal prophylaxis could therefore enhance both patient outcomes and healthcare efficiency, aligning national practice more closely with ERAS objectives.

When compared with international guidelines such as the ASA consensus and ERAS recommendations, our results highlight both areas of agreement and divergence. While most anesthesiologists in our study considered surgery type as a major determinant of prophylaxis, fewer incorporated patient-specific risk factors into their decision-making, despite international recommendations emphasizing both. This indicates a need for structured educational interventions and the integration of validated risk assessment tools into routine practice.

In addition, the study highlights the need for more effective translation of guidelines into daily workflows. Practical solutions could include developing national guidelines, incorporating electronic risk calculators into anesthesia records, and encouraging continuous professional development programs specifically targeting PONV prevention. Such measures could bridge the gap between awareness and practice and improve the standardization of care.

Although 90% of respondents reported high awareness of PONV guidelines, 42.5% indicated that they routinely apply prophylaxis to all patients without risk stratification. This discrepancy suggests that knowledge does not always translate into evidence-based practice. Potential explanations include institutional protocols that favor universal prophylaxis, perceived medicolegal concerns, and time limitations during clinical decision-making. Similar gaps between awareness and practice have been reported in international surveys, underscoring the need for more effective translation of guidelines into clinical workflows. To address this, interventions such as structured training programs, local guideline implementation, and the use of validated risk assessment tools may improve alignment between awareness and practice.

An important finding of our study was the discrepancy between reported awareness and actual clinical practice. Although 90% of participants stated that the survey increased their awareness of the importance of PONV prophylaxis, only 24% routinely followed guideline-based, evidence-driven strategies. This highlights a well-documented gap between knowledge and practice, which may stem from systemic barriers, limited resources, or entrenched habits in clinical decision-making. Similar gaps have been reported in previous literature, underscoring the need for targeted educational initiatives and institutional protocols to translate awareness into practice.

Our findings highlight several important gaps in PONV management. Risk assessments are often skipped due to time constraints, lack of institutional enforcement of standardized tools, and variability in clinical routines. In addition, the strong reliance on single-agent prophylaxis likely reflects both accessibility issues and anesthesiologists’ concerns regarding drug-related side effects. These trends underline a persistent knowledge-to-practice gap. To improve adherence, structured institutional guidelines should be implemented, multimodal antiemetic options should be made readily available, and targeted educational programs should be developed to promote evidence-based practice.

Future studies should aim to validate the questionnaire through pilot testing and psychometric analysis, recruit larger and more diverse samples to allow for multivariable statistical modeling, and include direct comparisons with patient outcomes. International multicenter studies could provide valuable insights into global practice variations and help identify best practices. Integrating electronic risk assessment tools into clinical workflows and evaluating their impact on patient outcomes would further strengthen the evidence base and guide the development of national and international guidelines.

Limitations

This study has several limitations. First, its cross-sectional design precludes establishing causality. Second, the data were collected through self-reported questionnaires, which may introduce recall or social desirability bias. The questionnaire was not subjected to pilot testing or psychometric validation, which may limit the reliability of the findings. Third, no direct comparisons with clinical outcomes were performed, which restricts the ability to assess the real impact of the reported practices. Fourth, the statistical analysis was limited to descriptive statistics and chi-square tests, without multivariable modeling or adjustments for multiple comparisons. In addition, the inclusion of anesthesiologists from different institutions with diverse working conditions may have contributed to variability in responses. Finally, as the study was conducted only in Turkey, the generalizability of the findings to other healthcare systems may be limited. This study has several limitations. First, as an observational survey, it is subject to self-report bias, since participants may have provided socially desirable responses rather than reflecting actual practice. Second, selection bias cannot be excluded, as participants were recruited through institutional mailing lists and professional societies. Third, the findings may not be fully generalizable, as practices may differ across institutions and regions. Finally, the questionnaire used in this study was not validated prior to distribution, which may affect the reliability of the reported responses.

Conclusion

The rate of anesthesiologists who reported an increased awareness of PONV prophylaxis among those who participated in this study was 90.0%. The primary objective of this study was to draw attention to the need for increased sensitivity among anesthesiologists regarding this issue. The European Society of Anesthesiology and Intensive Care, along with the ERAS guidelines, advocates for a multidisciplinary approach to the management of PONV. In current clinical practice, PONV risk assessment and prophylaxis remain overlooked. Therefore, the integration of PONV scoring systems into preoperative anesthesia assessment protocols as part of routine practice is essential to determine the most appropriate prophylaxis and treatment strategies on a patient-specific basis. Our findings suggest that while awareness regarding PONV prophylaxis can be improved through reflective tools such as surveys, PONV risk assessment, and evidence-based prophylaxis remain underutilized in daily practice. Future strategies should aim to bridge this gap by enhancing both awareness and implementation. In conclusion, our survey revealed that although anesthesiologists demonstrate high levels of awareness regarding the importance of PONV prophylaxis, risk assessment, and evidence-based multimodal prophylaxis remain underutilized in clinical practice. These results emphasize the need for greater alignment between knowledge and practice. Future initiatives should focus on integrating standardized risk scoring systems into routine perioperative care, improving access to multimodal antiemetic strategies, and enhancing educational efforts to promote evidence-based adherence.

Supplemental Material

sj-docx-1-smo-10.1177_20503121251397055 – Supplemental material for Investigation of the attitudes and behaviors of anesthesiologists regarding the prophylaxis and treatment of postoperative nausea and vomiting

Supplemental material, sj-docx-1-smo-10.1177_20503121251397055 for Investigation of the attitudes and behaviors of anesthesiologists regarding the prophylaxis and treatment of postoperative nausea and vomiting by Eskandar Abdullah Ali Ghallab and Ferda Yaman in SAGE Open Medicine

Footnotes

Acknowledgements

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this article.

ORCID iDs

Eskandar Abdullah Ali Ghallab

Ferda Yaman

Ethical considerations

All procedures performed in this study were in accordance with the ethical standards of institutional and national research committees and with the 1964 Helsinki declarations and their later amendments. The protocol of this study was approved by the Local Ethics Committee of the Eskisehir Osmangazi University Faculty of Medicine (date/number: September 28, 2021/04).

Consent to participate

Written informed consent was obtained from all participants prior to their involvement in the study.

Author contributions

Eskandar Abdullah Ali Ghallab, Ferda Yaman: conceptualization, data collection, data analysis, methodology. Ferda Yaman: reviewing and editing, supervision, writing—original draft, article submission.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Data sharing is not applicable to this article, as no datasets were generated or analyzed during the course of this study.

Supplemental material

Supplemental material for this article is available online.

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