The incidence of postoperative nausea and vomiting (PONV) after a standard anaesthetic technique consisting of inhalational anaesthetics and opioids and no PONV prophylaxis is up to 30%. Being one of the most common complaints following surgery under general anaesthesia, it is not surprising that PONV is a considerable cause of dissatisfaction with recovery from anaesthesia and remains one of the most commonly used items in surveys assessing patient satisfaction with the perioperative period and in scoring systems for the quality of recovery following anaesthesia. The weakest link in the chain from research to patient benefit is the implementation of well proven strategies. Rather than simply following existing consensus guidelines, anaesthesiologists should critically assess whether the algorithms introduced produce the desired effect. Risk-adapted strategies may work, but recent implementation studies suggest that compliance with these algorithms may be poor and that high-risk patients often do not receive appropriate antiemetic prophylaxis. Multimodal prevention may represent a more simple approach and, thus, a more reliable strategy to reduce the incidence of PONV. Such an approach would circumvent the inherent weaknesses of the need to undertake a risk assessment for each individual patient. Anaesthesiologists need to know about the new agents available to manage PONV, such as the NK1-antagonists or the newer 5-HT3 antagonists, but should not forget the traditional and well established antiemetics that are valuable components in the current portfolio. The low cost of most of the currently available antiemetics and the low incidence of side-effects suggests that a liberal antiemetic prophylaxis regimen is a meaningful option in order to eliminate or substantially reduce the 'big little problem'.