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Anesthesia

Type of anesthesia for abdominoplasty?

10/10/2008

Question:

I`m scheduled to have abdominoplasty surgery; I`m a 51 year old guy and have no medical problems. I have had several previous surgeries, but unfortunately I get really sick when I get the inhalation agents.....even just nitrous at the dentist or the addition of sevoflurane when I had my knee fixed caused severe nausea and vomiting, and the anti-nausea drugs droperidol and zofran gave me hives. I did have elbow surgery, both times with propofol/fentanyl, once awake and once asleep (TIVA) and it was perfect, no problems. I don`t want to do spinal due to spinal issues and was wondering if it would be possible to do the abdominoplasty (surgeon suggests a general) with just propofol/fentanyl? My surgeon is super and she says that the procedure is long, but that anesthesia options are pretty open. Unfortunately, the hospital will not answer questions about anesthesia until the day of surgery (seems unreasonable), so I was wondering what you think. The surgeon said that she would do the procedure with lots of local, and said that severe nausea and vomiting would be a real problem if I got the inhalation agents. So far, I`m thinking of just the local option. Any comments are appreciated.

Answer:

Postoperative nausea and vomiting - "PONV" - is a really nasty side effect of anesthesia and surgery. Total intravenous anesthesia (TIVA) is a good option for anyone who has suffered from PONV. TIVA is less popular in the US than in Europe, partly because the FDA has not yet licensed certain kinds of infusion pumps that make it a bit easier to do TIVA, and partly because, well, just because. TIVA is no less safe or effective than anesthesia using inhalational agents (gas) like sevoflurane.

As you know, this is a discussion that you should be having with your anesthesiologist, not me. Whatever I say about the anesthetic options is said without reference to your general health, the resources available in your hospital, and the preferences of your surgeon - all important factors in coming up with a good anesthetic "plan".

General anesthesia based on propofol and fentanyl is an entirely feasible option. One problem with your recipe however is that fentanyl, along with its cousins like sufentanil, morphine and other opioids, is a prominent cause of nausea. Keeping the opioids to a minimum, and using pain-killer drugs like the "NSAIDs" (ibuprofen and its relatives) or even small doses of ketamine will help. Local anesthesia will help reduce the amount of anesthesia (and fentanyl) you need and therefore the likelihood that you have PONV. Although you are allergic to Zofran (ondansetron) and droperidol (both of them?) there are other antiemetics in the same groups and in other chemical groups, such as dolasetron, haloperidol, prochlorperazine, and scopolamine, that can be tried.

Acupuncture, acupressure and transcutaneous electrical stimulation of acupuncture points can help. Many patients have their worst symptoms several hours after a procedure, on their way home, and it is ideal therefore if oral antiemetic medications are continued for about 24 hours.

I hope that you'll be able to have your surgery without too much anxiety about the PONV issue. With suitable attention to drugs, dosages, and other factors it should be possible for your risk of PONV to reduced to a low level.

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Response by:

Gareth S Kantor, MD Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University