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Postoperative Nausea and Vomiting with Plastic Surgery: A Practical Advisory to Etiology, Impact, and Treatment

Friedberg, Barry L., M.D.

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 608e-609e
doi: 10.1097/PRS.0000000000004755

Goldilocks Anesthesia Foundation, P.O. Box 10336, Newport Beach, Calif. 92658,

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Although Drs. Manahan et al.1 correctly identify continuous propofol infusion as a preferred approach to prevent postoperative nausea and vomiting, several errors appear in their otherwise fine article. Table 1 mistakenly states as an Apfel postoperative nausea and vomiting risk factor “active smokers,” whereas the text correctly states “nonsmokers.”

The authors claim that ketamine should be avoided.2,3 Propofol-ketamine anesthesia4 has been subsequently cited by more than 175 later authors including Apfel, who cited it in Miller’s Anesthesia, the most prestigious textbook in the field.5,6 The published 0.6 percent postoperative nausea and vomiting rate is remarkable because all patients received before injection 50 mg of intravenous ketamine, were Apfel-defined as high risk, and yet none received antiemetic medication. Apfel’s postoperative nausea and vomiting chapter in Miller also states, “As long as emetogenic agents are part of the anesthetic regimen, the use of anti-emetics is of limited utility.”

The authors are correct when stating, “To control postoperative nausea and vomiting, the surgeon and anesthesiologist must work in concert.” Brain-monitored, propofol-ketamine anesthesia with local analgesia is simple to learn. Teaching cooperation is not. These references may help the authors emulate my 25-year success essentially eliminating postoperative nausea and vomiting.7–10

The use of the real-time electromyographic signal of the BIS (Medtronic, Minneapolis, Minn.) brain monitor clarifies the issue of “too light” versus “more local” in a dispassionate, numerically reproducible manner. With propofol titrated to BIS between 60 & 75 with baseline electromyogram (EMG), the patient is asleep and amnestic; patient movement without EMG activity is an indication for more local anesthetic in the immediate area of dissection.11 Vasoconstriction does not equal adequate analgesia. Elimination of movement will occur 98 percent of the time.

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There are no financial disclosures to report for the author or the nonprofit Goldilocks Anesthesia Foundation.

Barry L. Friedberg, M.D.Goldilocks Anesthesia FoundationP.O. Box 10336Newport Beach, Calif.

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1. Manahan MA, Johnson DJ, Gutowski KA, et al. Postoperative nausea and vomiting with plastic surgery: A practical advisory to etiology, impact, and treatment. Plast Reconstr Surg. 2018;141:214222.
2. Chatterjee S, Rudra A, Sengupta S. Current concepts in the management of postoperative nausea and vomiting. Anesthesiol Res Pract. 2011;2011:748031.
3. Apfel CC, Philip BK, Cakmakkaya OS, et al. Who is at risk for postdischarge nausea and vomiting after ambulatory surgery? Anesthesiology 2012;117:475486.
4. Friedberg BL. Propofol-ketamine technique: Dissociative anesthesia for office surgery (a 5-year review of 1264 cases). Aesthetic Plast Surg. 1999;23:7075.
5. Apfel CC. Postoperative nausea and vomiting. In: Miller’s Anesthesia. 2010:7th ed. Philadelphia: Elsevier; 27292756.
6. Apfel CC. Postoperative nausea and vomiting. In: Miller’s Anesthesia. 2015:8th ed. Philadelphia: Elsevier; 29472973.
7. Friedberg BL. A role for the anesthesiologist in elective cosmetic surgery? Plast Reconstr Surg. 2003;111:953955.
8. Friedberg BL. A role for the anesthesiologist in elective cosmetic surgery. Plast Reconstr Surg. 2003;111:13651366.
9. Friedberg BL. Cosmetic surgery: Postoperative pain and PONV—Dissociative anesthesia reconsidered. Plast Reconstr Surg. 2010;125:184e185e.
10. Friedberg BL. Can Friedberg’s triad solve persistent anesthesia problems? Over-medication, pain management, postoperative nausea and vomiting. Plast Reconstr Surg Glob Open 2017;5:e1527.
11. Friedberg BL. Friedberg BL. The dissociative effect and preemptive analgesia chapter. In: Anesthesia in Cosmetic Surgery. 2007:New York: Cambridge University Press; 3946.
Copyright © 2018 by the American Society of Plastic Surgeons