The frequency of postoperative nausea and vomiting in young women receiving general anesthesia for breast augmentation surgery has been reported to be as high as 60 to 80 percent. So it’s not surprising that patients are as fearful of postoperative nausea and vomiting as they are of postoperative pain.

Over the last 10 years, I’ve performed breast augmentation surgery under general anesthesia on more than 3,000 patients. In each case, I placed saline breast implants behind the muscle. During this period, in conjunction with the anesthesia department at Nazareth Hospital in Philadelphia, I developed a protocol of medications and anesthetics to attack the multiple pathways that contribute to nausea and vomiting.

Because I believed that patient satisfaction was linked to low incidences of PONV, I conducted a patient survey to get a more objective measure of the value of this particular protocol. The survey, conducted over seven months, included 241 women ages 18 to 57.

The Protocol:Before surgery, all but two patients (who were allergic to sulfa) received 200 mg of Celebrex capsule, a cyclooxygenase (COX)-2 inhibitor, along with Alka Seltzer Gold or Bicitra. They were also given the option of taking 5 mg of Valium. Six patients with a prior history of nausea and vomiting were given 40 mg of Emend within three hours of surgery. (Benadryl was withheld on these six patients to evaluate the effects of Emend.) All patients received intravenous propofol, Versed, and fentanyl for the introduction of general anesthesia.

During surgery, women were given intravenous Zofran (4 mg), Benadryl (25 mg), and Decadron (8 mg). Sevofluorane gas was used, and no nitrous gas was given.

Postoperatively, patients were advised to take Celebrex. They were also given prescriptions for Zofran ODT 4 mg and Valium 5 mg. Patients were also advised that they could use antacids like Rolaids or Tums for postoperative nausea if needed.

The Results:Patients filled out a questionnaire at their first post-operative visit, five to seven days after surgery. They were asked to evaluate their level of nausea and vomiting on the day of surgery, the day after surgery and the second day after surgery, and their satisfaction with the overall surgical experience, using a scale of 0 to 10, with 10 being the most severe.

In all, 73% of the 241 patients reported no nausea and vomiting on the day of surgery. The numbers of patients who reported no nausea and vomiting on the first and second days after surgery were similar, at 73% and 75.5%, respectively. On average, the remaining 27% had some PONV (“3” on the 0 to 10 scale) on all 3 days. A total of 94% of patients reported a “10” to rate their overall experience, and 90% gave a “10” rating for the results of their operation.

Conclusion:My approach, which evolved over 10 years with 3,000 patients, has improved my results from several days of extreme postoperative nausea and vomiting to almost zero. I attribute much of this success to the use of Decadron, Zofran, Benadryl and Emend, all of which may affect multiple pathways and nausea receptor sites. During surgery, I use a laryngeal mask airway (LMA) and eliminate nitrous; I believe this may help decrease post-op nausea and vomiting. I also use Celebrex, which may possibly lower the amount of narcotic needed during and after surgery.

The obvious result of minimal to no nausea or vomiting after breast augmentation surgery is an outstanding level of patient satisfaction. My patients used to call me for three to four days after surgery, uncomfortable and unhappy about their nausea and vomiting. Now, the phone is silent.