Expert: JM Starkman, MD - 9/14/2010

Question
Hi,
I got an operative hysteroscopy under conscious sedation and I've been sick after.
They used 750ug Alfenta, 100 ug Fentanyl, 142mg Propofol and 5 or .5mg Versed(isn't clear from the anesthesia graphic). Op lasted 45 minutes. Been 30 minutes in recovery room without any problems...I guess :) Moderate pain disappeared completely within 15 minutes so I didn't receive more painkillers while there and after.
Got nauseous in the outpatient room, 45 minutes after the end of the surgery . Received 10mgIV Metoclopramide but didn't work. Received 4mgIV Zofran 10 minutes after but...didn't work either. PONV  lasted for about 3 hours. My question is, could the PONV  be caused by the painkillers but these antiemetic drugs just don't work on me? Could it be caused by propofol and/or versed ? What could be my "PONV management plan" if I end up in surgery again?
Also, I'm wondering about the 5 or .5mg of Versed; if it's .5 than why only .5? Is it a dot on the graphic to indicate the time of injection or could I have reacted negatively so, he didn't give me more? My vital signs haven't seemed fluctuate a lot but I'm no anesthesist for interpreting the graphic.
I have to say that I didn't expect sedation. I have been served the "something to relax" line so I expected effects of a mild painkiller only during the operation but got more than that, which I've HATED.


Thanks for your time

Answer
So many good questions..................

ALL narcotics (e.g. Alfentanil) cause nausea and vomitting and their use must be judicious in patients who, like you, are susceptible to PONV (Post-Operative Nausea and Vomitting).  Once the narcotic is affecting your nervous system to cause this problem alleviating the symptoms with more drugs is often not as effective as simply letting the narcotic 'wear off' (metabolize).  But try telling this to nurses in recovery rooms or patients themselves who want doctors to "do something"---and you'll talk yourself silly.

I like the 0.5 mg of Versed.  Someone (?nurse anesthetist ?anesthesiologist) thought to carefully utilize the drug for its advantages during a short surgery yet not 'overdo it' with a much larger and/or longer acting dose. No negative reaction here.

For the future, talk to your anesthesiologist WELL IN ADVANCE of surgery and formulate a plan to avoid PONV. Keep the copy of your alfenta anesthetic record (the graphic)  to show him so he has a starting point from which to formulate an anesthetic plan customized for you and your surgeon's needs.  

As far as getting what you 'didn't expect'-- I'm really not sure what YOU feel is the difference between "something to relax" and a "mild painkiller".  This seems to be a matter of communication which, again, should be settled WELL IN ADVANCE of planned anesthesia/surgery to the patient's, surgeon's and anesthesiologist's agreement.