According to data from the National Survey of Ambulatory Surgery, the following 6 procedures carry a particularly high risk of post-op nausea and vomiting. We asked an anesthesia provider for her views on what causes these complications and whether they might be preventable.
1. Resection of the septal nasal submucosa. Expect up to 20% of patients to experience nausea after undergoing deviated septum surgery. About 6% will also suffer vomiting.
2. Tonsillectomy and adenoidectomy. Up to 4% of patients (undergoing the procedures individually or jointly) will experience nausea, and as many as 2% will vomit.
With procedures 1 and 2, "the patient often swallows a small amount of blood either during surgery or in post-op," says Karen Trask, CRNA, of South Shore Anesthesia Associates in Weymouth, Mass. "Nothing you can do about it."
3. Rotator cuff repair. Up to 4% of patients experience nausea and 1% will vomit. Using regional techniques, specifically interscalene blocks, instead of or as a supplement to general anesthesia "would significantly cut down on narcotics" perioperatively, she says. "As for post-op at home: This is an extremely painful surgery. Patients will use a lot of narcotics post-op."
4. Lumpectomy. 5% of patients experience nausea and up to 2% progress to vomiting. Since women tend to have higher incidence rates for PONV and since nearly all of these patients will be women, not much can be done in the way of prevention, says Ms. Trask.
5. Laparoscopic cholecystectomy. Up to 5% of patients experience nausea and 1% vomit. The probability of intraperitoneal irritation is high here, she says, with not much recourse for providers.
6. Knee arthroscopy Expect 2% to be nauseated and about half of those to vomit. Comparatively, that number isn't too bad, she says, nor are the rest. "I believe national PONV rates are around 15%, so these rates are actually quite good," she says.
While identifying the cause and possible prevention of PONV depends on several factors, including the type of anesthesia used and when the complication is occurring (in PACU or at home during the use of pain meds), you have a couple of options, says Ms. Trask.
Use more than 1 modality. "This will hit different receptor sites in the brain. Decadron, Reglan, Zofran — this is a pretty good combo," with the first 2 drugs administered up front and the third 15 minutes before the case ends. Also consider a scopolamine patch 24 hours pre-operatively.
The use of regional anesthesia, by itself or as a supplement, can cut down on the need for narcotics.
"Consider avoiding N2O, which can increase the risk of PONV.
Use Toradol as well as the new IV acetaminophen to decrease narcotic use.
Advise patients, once home, to take their pain meds with food.
Have surgeons prescribe post-op anti-emetics, especially after high-risk procedures.
David Bernard
