Incidence of PONV after propofol ketamine deep sedation and intercostal regional block for tumour related breast surgery.

C G Pollock. Department of Anaesthesia, Hull and East Yorkshire Hospital Trust

Introduction:

Postoperative nausea and vomiting continues to be a significant blot on the post anaesthetic landscape. A typical approach is to continue giving a “standard anaesthetic” and to add in antiemetics. A more rational approach is to leave out the emetics. Propofol is antiemetic and low dose ketamine is not associated with nausea.

Methods:

Unpremedicated patients scheduled for wide local excision(WLE) or mastectomy(Mx) +/- axillary sampling were induced with TCI propofol in the lateral position. After loss of consciousness a bolus of ketamine 50mg was given to minimise movement while the intercostal blocks were performed from T6 to T2, injecting 5mls of mixture of 1%lidocaine with epinephrine and 0.25% bupivicaine at each level, then a supraclavicular block in addition. Surgery commenced straight away. In PACU any pain was initially managed with 1g iv paracetamol ,then titrated morphine up to 10 mg if necessary (and ondansetron 4mg + cyclizine 10mg).Patients were reviewed the following day.

Results:

929 patients were reviewed.Mean (range)

Age 58 (28-92)yrs: weight 70(41-130)kg: duration: WLE 40(20-110), Mx 76(22-215) mins. 21% of patients needed morphine in PACU median dose 6mg. The 24 hr incidence of vomiting was 0.27% and of nausea 2.2%.

Discussion:

PK with intercostal blockade has a PONV rate of 2.5%, this compares with Friedberg’s rate of 0.6% using PK in cosmetic surgery (1); with 33% in breast surgery with general anaesthesia and paravertebral block (2) or with 20% in a conscious sedation technique using midazolam, alfentanil and paravertebral block (3).

Avoiding emetic anaesthetic agents significantly improves the patient’s postoperative experience.

 References:

1) Friedberg BL:Propofol-ketamine technique: Dissociative anesthesia for office surgery. Aesth Plast Surg 23:70,1999

2) Kairaluoma etal Single injection paravertebral block before general anaesthesia. Anesth Analg 99:1837,2004

3) Coveney etal: Use of paravertebral block anesthesia in the surgical management of breast cancer. Ann Surg 227:496,1998