June, 2009

UP TO 30 PERCENT OF THE GENERAL POPULATION STILL EXPERIENCES NAUSEA AND VOMITING AFTER SURGERY. Reducing that number should be a priority for all of us. Preventing PONV boosts patient satisfaction, ensures faster recovery, and saves surgery facilities money. Fortunately, there is a simple formula for achieving this: Cut down the use of volatile anesthetics and post-op opioids, two agents that tend to cause PONV.

Instead of gas anesthesia, consider using total intravenous anesthesia with propofol as the primary sedative. Studies show that IV anesthesia cuts PONV by 20 to 30 percent, and propofol, in particular, enables quick, smooth recovery. It also has antiemetic properties. When patients are at high risk for PONV, consider using dexmetatomadine rather than remifentanil as an adjunct, since it is a non-opioid sedative that also has some analgesic properties.

Instead of depending on post-op morphine for pain control, administer single-shot peripheral nerve blocks. When indicated, we use PNBs as the primary surgical analgesic, and we bill for them as such. The prolonged pain control that a successful block provides helps obviate the need for morphine.

This two-pronged approach costs slightly more up front than traditional gas anesthesia, and IV anesthesia requires heightened vigilance from the anesthesiologist. But if it prevents even a few incidents of PONV, it’s worth it. The most important reason is patient satisfaction; research shows that patients are willing to pay up to $100 to avoid vomiting. But another very important reason is that PONV prevention can save surgery facilities money. PONV adds cost to a case due to prolonged recovery, nursing interventions, the need for rescue drugs, and case delays due to a full PACU. In fact, research shows that the cost associated with a single episode of nausea and vomiting in the surgicenter setting is $415, and that vomiting is the number one reason for unplanned admissions among same-day surgery patients. PONV causes suffering and dread for patients, and it creates delays and additional costs for surgery facilities. It’s in everyone’s best interest to work to stamp it out, by reducing or eliminating the agents that cause it.

Dr. Gadsden is Director of the Regional Anesthesia Fellowship Program and Associate Residency Program Director with St. Luke's-Roosevelt Hospital Center. He is also Assistant Professor of Clinical Anesthesiology with Columbia University College of Physicians and Surgeons, New York, NY.