Abstract Postoperative nausea and vomiting (PONV) is a common and distressing event following surgery. About one in four patients are affected. It has an associated morbidity and mortality caused by both the direct effects of vomiting and the difficulties in managing other aspects of postoperative care. This article discusses the five principal areas to be considered when assessing and managing the risks of PONV: premorbid patient issues; the immediate preoperative situation; the nature of the proposed surgery; anaesthetic technique; and the postoperative circumstances. Advances in the understanding of normal physiology and the pathophysiological states induced by any surgical intervention have revealed that a multimodal approach is essential to manage this condition. Treatment must begin in the preoperative period and aim to reduce both physical and psychological risk factors. The anaesthetic technique must be tailored to the type and length of surgery, and a postoperative plan created to reduce the incidence of PONV and provide effective treatments. The importance of the role of polypharmacy is also discussed.