The Surgery Is Over, Why Are We Still Sick?

November 3 2026

Have you or anyone you know went through any operation before?

Whatever the answer may be, good, I hope you don’t have to go through it, and if you did, I hope your recovery was smooth and easy. Imagine waking up after an operation. The surgery has gone well. Your vital signs are stable, the surgeon is satisfied with the outcome, and you are finally out of the operating theatre.

But there is one problem.

You don’t feel too good. You feel nauseated. Your stomach churns, your mouth rapidly fills with saliva, and before long, you find yourself vomiting. I’ve always hated the whole experience of vomiting. The aura you feel in your head as a premonition before the violent expulsion of the spoilt food you just had, add to that, the strong sour taste you feel when food and fluid gushes out through your oesophagus, mouth and out, it’s just severely unpleasant. Instead of looking forward to going home, you are struggling to feel comfortable enough to sit up, drink water or even keep your eyes open. For many patients, this is not an unfamiliar experience. Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications following surgery and anaesthesia. Although it is rarely life-threatening in otherwise healthy individuals, its impact should not be underestimated. It can cause considerable discomfort, delay recovery and hospital discharge, increase healthcare costs and, in certain circumstances, contribute to complications such as dehydration and aspiration. For someone who has just undergone surgery, the experience can be particularly frustrating. After enduring the anxiety of an operation, the last thing a patient wants is to spend the next few hours feeling sick.

Why does it happen?

The human body has an elaborate defence mechanism against substances that may be harmful. Vomiting is one such mechanism, coordinated by complex neural pathways involving the brainstem, gastrointestinal tract and several chemical receptors. Unfortunately, anaesthesia and surgery can inadvertently activate these pathways. Most of our anaesthetic medications, particularly inhalational anaesthetic agents and opioids, can increase the likelihood of nausea and vomiting. Surgical factors, hormonal influences and individual susceptibility also play a role. Some patients are simply more vulnerable than others. A history of motion sickness or previous postoperative nausea, being female, being a non-smoker and requiring postoperative opioid medication are among the recognised risk factors. This means that preventing postoperative nausea is not simply a matter of giving every patient the same medication. It requires understanding the individual patient, anticipating their risks and tailoring the anaesthetic plan accordingly.

Can we prevent it?

The approach to postoperative nausea and vomiting has evolved considerably over the years. Traditionally, anti-nausea medications were often administered when patients began experiencing symptoms. While this remains important, modern anaesthesia increasingly emphasises prevention rather than waiting for nausea to occur. The recently published Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting, released in September 2026, reflect this evolving approach. Good news for our patients. One of the central messages is the importance of multimodal prevention. Rather than relying on a single medication, anaesthesiologists can combine interventions that work through different biological pathways.These may include medications such as dexamethasone and ondansetron, which act on different receptors involved in the vomiting process. Depending on the patient's risk profile, other anti-nausea medications may also be considered.

But prevention does not begin and end with medication.

The choice of anaesthetic technique matters too. Propofol-based total intravenous anaesthesia (TIVA), for example, can reduce the risk of postoperative nausea compared with conventional inhalational anaesthesia. Minimising opioid exposure through multimodal pain management, using regional anaesthesia where appropriate and maintaining adequate fluid balance are other strategies that can contribute to a smoother recovery.

In essence, the goal is to address several contributing factors simultaneously rather than attempting to suppress nausea through a single intervention. It is easy to measure the success of surgery by looking at whether the operation was technically successful, whether complications were avoided and whether the patient survived the procedure. But what about the patient’s wellbeing and overall satisfaction? For patients, the experience of recovery matters just as much. Being able to wake up comfortably, drink without feeling sick, move around and return home without unnecessary delays are meaningful aspects of healthcare quality. As anaesthesia continues to advance, our responsibility is not merely to ensure that patients do not feel pain or remain unconscious during surgery. It is also to ensure that they wake up well. Because a successful operation should not end at the moment the surgeon puts down the scalpel. It should extend all the way to the patient's recovery.

Reference

1. Gan TJ, Jin Z, Ayad S, Belani KG, Habib AS, Meyer TA, Urman RD, Andrew BY, Bergese SD, Chung F, Diemunsch P, Kovac AL, Candiotti K, Englesakis M, Grant MC, Hedrick TL, Huang H, Kranke P, Lloyd SJ, Manahan MA, Minkowitz HS, Philip BK, Phillips BJ, Simpson KD, Stever J. Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: Executive Summary. Anesth Analg. 2026 Sep 1;143(3):497-513. doi: 10.1213/ANE.0000000000007816. Epub 2025 Nov 14. PMID: 41237407.