What About Preventing PONV?
The only shortcoming in Dr. Alan P. Marco's PONV article ("
How to Fine Tune Your PONV Regimen," June, page 40) was failing to mention the possibility of using a low emetogenic anesthetic technique1 to avoid creating the problem in the first place.
According to Dr. Marco's stratification of risk, my exclusively office-based plastic surgery practice - which is 80% female, the overwhelming majority of them non-smokers with 35% previous PONV - would be moderate to high risk. Avoiding the routine use of opioids as well as inhalation vapors, my 10-year propofol ketamine experience has had 13 emetic events in 2,680 patients or a 0.5% PONV rate without the use of any prophylactic measures Dr. Marco suggests. If a patient has had previous PONV, he is likely to be opioid sensitive. This is analogous to being a waiting bucket of gasoline. The routine use of any opioids is like the proverbial match into the gasoline. As I tell my patients, if you don't toss the match into the gasoline, you don't have to worry about which fire extinguisher(s) to use.
1. Friedberg BL. Propofol ketamine technique: dissociative anesthesia for office surgery (a five year review of 1,2364 cases). Aesth Plast Surg 1999;23:70.
Barry L. Friedberg, MD
Cosmetic Surgery Anesthesia
Corona del Mar, Calif.
drfriedberg@doctorfriedberg.com
Dr. Marco replies:
Dr. Friedberg has raised an important point. It may be better to avoid opiod-induced PONV than to worry how to treat it. Opiod-sparing techniques, such as the propofol-ketamine technique he advocates as well as the concomitant use of local and regional anesthetics, NSAIDs, and potentially alpha-agonists (clonidine) and NMDA receptor antagonistsm may reduce the incidence of PONV.
However, his report of his large case series does not distinguish between the avoidance of opiods and other factors, such as surgical procedure, degree of postoperative pain, or the use of propofol itself (which in some studies has be found to be anti-emetogenic). Also, his experience with primarily cosmetic surgery patients may not be directly transferable to a broader mix of cases including gynecologic, orthopedic, ophthalmologic and general surgery cases. Nevertheless, I would agree that in situations where opiod-sparing techniques are possible, it is reasonable to use them in hopes of reducing PONV.
Alan P. Marco, MD
Associate Professor
Department of Anesthesiology
Medical College of Ohio
amarco@mco.edu
Clarifications
- In our July 2002 article, "What's New in Cataract Extraction," the article states that the Horizon Phacoemulsification system from American OptiSurgical, Inc., offers air venting. The system is actually bottle vented. Outpatient Surgery regrets any confusion or inconvenience the error may have caused.
- In our July 2002 article, "How We Implemented Image Guided Surgery," we failed to list BrainLAB in the article's list of manufacturers. Contact BrainLAB at (800) 982-7229 or at www.brainlab.com.
