Waking up on a TIVA after inhalational exposure -- PONV

[patriot6]

---

Members don't see this ad.

I recently had a complicated case that involved a sternotomy in a patient with a history of very severe PONV. We elected to use iso for maintenance and max out multimodal PONV coverage with the intention to wake up on a TIVA after the difficult portions of the case were complete. Does anyone know if the transition to a TIVA decreases the incidence of PONV (perhaps back to the baseline risk) -- or does any exposure to inhalational increase the risk of PONV? The gas was gone for ~ 1-2 hours before this patient woke up.

No PONV.

 

[coffeebythelake]

I recently had a complicated case that involved a sternotomy in a patient with a history of very severe PONV. We elected to use iso for maintenance and max out multimodal PONV coverage with the intention to wake up on a TIVA after the difficult portions of the case were complete. Does anyone know if the transition to a TIVA decreases the incidence of PONV (perhaps back to the baseline risk) -- or does any exposure to inhalational increase the risk of PONV? The gas was gone for ~ 1-2 hours before this patient woke up.

No PONV.

Dont know if it has been studied. I imagine it would be intermediate between gas vs tiva

 

[deleted171991]

Most PONV is not from gas, it's from opiates (plus dehydration and stress). Hence you played with iso for hours and nothing bad happened. QED. I doubt that the TIVA at the end would have fixed a strong PONV from the gas.

Even when from opiates (or gas), what matters many times is the amount. I admit, there are some patients who will get nauseous even when shown the fentanyl vial, but they are much rarer than we think (usually they are the ones who report PONV with multiple anesthetics, at various ages, almost without exception). In these latter cases, I run some form of IV anesthesia, and minimize/eliminate gases (if the patient is not muscle-relaxed - I would rather apologize for nausea than awareness).

In the right hands, PONV is rarely an issue even with opiates + nitrous + sevo. If we were to believe the academic legends, every PONV patient should get only TIVA, for life.

 

[deleted875186]

Most PONV is not from gas, it's from opiates (plus dehydration and stress). Hence you played with iso for hours and nothing bad happened. QED. I doubt that the TIVA at the end would have fixed a strong PONV from the gas.

Even when from opiates (or gas), what matters many times is the amount. I admit, there are some patients who will get nauseous even when shown the fentanyl vial, but they are much rarer than we think (usually they are the ones who report PONV with multiple anesthetics, at various ages, almost without exception). In these latter cases, I run some form of IV anesthesia, and minimize/eliminate gases (if the patient is not muscle-relaxed - I would rather apologize for nausea than awareness).

In the right hands, PONV is rarely an issue even with opiates + nitrous + sevo. If we were to believe the academic legends, every PONV patient should get only TIVA, for life.

Not sure I agree with everything you said, but I agree more PONV is from opioids, pain, and surgery. Just look at rates of post discharge nausea and vomiting, they are unaffected by TIVA versus gas.

 

[Hork Bajir]

Look up studies on “propofol sandwich” technique. Prop itself is an antiemetic, and the plasma concentration needed to see antiemetic effect is quite low (easily achievable with a 20-30mg bolus). I believe there is some data to show that prop infusion during the case or at wake up decreases PONV, but not as much as a complete TIVA.

What has NOT been studied, to my knowledge, is whether or not switching to TIVA at the end of the case is as good as total TIVA if the volatile is totally gone at the time of wake up (end tidal [ ] of 0 for some amt of time)