Discussion: Postoperative Nausea and Vomiting with Plastic Surgery

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The authors are plastic surgeons tasked by the American Society of Plastic Surgeons Patient Safety Subcommittee to create this consensus-based patient safety advisory, entitled “Postoperative Nausea and Vomiting with Plastic Surgery: A Practical Advisory to Etiology, Impact, and Treatment.”
The authors begin by describing the magnitude of postoperative nausea and vomiting (PONV). More than 25 percent of our patients suffer this problem. This is the most common cause of hospitalization after ambulatory surgery. PONV can also contribute to complications such as hematoma, incisional dehiscence, respiratory compromise, pain, longer hospital stay, slower recuperation, and patient dissatisfaction. This is a huge dragon that remains to be slain.
The authors do an excellent job of describing good strategies of avoiding nausea and vomiting when sedation is inevitable. They also point out that nausea and vomiting can be avoided when surgeons use pure local anesthesia. The article is very well written and comprehensive.
My main problem with the article is that it does not go far enough in getting plastic surgeons to explore eliminating PONV by avoiding sedation altogether and using pure local anesthesia much more often than they do now. It receives a polite mention in the article, but this point does not even appear in the summary recommendation. My number one point in the summary recommendation would have been the following: Avoid nausea and vomiting altogether by learning how to inject local anesthesia in a minimally painful fashion so that sedation is not required at all. Many plastic surgery procedures can now be performed wide awake in this fashion. This is especially true now that we can all easily and reliably tumesce large body areas with minimal pain local anesthesia injection in a reliable fashion with filler cannulas.1–3
The authors state that surgery is a risk factor for PONV. I would respectfully disagree. Let us call a spade a spade. It is the sedation component of our surgery that causes the nausea and vomiting, and not the surgery component. I do not know what kind of operation causes nausea and vomiting. Most of my surgery is under pure local anesthesia, and I just do not see nausea and vomiting. How many of you have had nausea and vomiting after your dental operation where no sedation is involved? After a nevus or simple skin cancer excision? After a carpal tunnel under pure local anesthesia? Never say never, but pretty much, almost never. The only rare time I have seen nausea with pure local anesthesia was one time in 33 years when one of my residents generated a vasovagal attack with local anesthetic injection. She did not recognize the impending faint and she did not get the patient’s head down to avoid the attack by restoring blood flow to the brain. That patient vomited because of the injection-triggered vasovagal attack, not because of the surgery or the local anesthesia.
The second area that does not receive enough attention in this article is the encouragement of avoiding postoperative narcotics altogether. Almost none of my face-lift, breast augmentation, breast reduction, abdominoplasty, or hand surgery patients receive intraoperative or postoperative narcotic medications. What they do receive is proper education on how to take pain killers such as ibuprofen and acetaminophen, and detailed simple instructions on how to tailor postoperative activity to their pain. We educate them in pain guided healing. I fully realize that most of us deal out narcotics like candy postoperatively, because that is what our chief resident taught us to do in residency.
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