Choice of Anesthetic Management Can Reduce the Use of Rescue Antiemetics After Bariatric Surgery but Effects Are Short-lived

Abstract

Background Postoperative nausea and vomiting (PONV) is frequent after bariatric surgery. We hypothesized that when compared with a volatile-based technique incorporating propofol infusions, the need for rescue antiemetics would be reduced by the use of two strategies: 1) the addition of dexmedetomidine infusions, and 2) the avoidance of opioid and volatile anesthetics, and that this reduction would be observed in the PACU following PACU discharge. Methods In this retrospective observational study we included patients undergoing bariatric surgery from 2018–2022 who received one of three anesthetic strategies: 1) volatile anesthetic and propofol infusion (VOL + PROP), 2) VOL + PROP with the addition of dexmedetomidine (DEX), or 3) opioid-sparing total intravenous anesthesia (PROP + DEX). Inverse probability of treatment weighting analysis determined the association between the need for rescue-antiemetics in the PACU following PACU discharge. Results 332 patients received VOL + PROP, 354 VOL + PROP + DEX, and 166 PROP + DEX. PROP + DEX received fewer rescue antiemetics in PACU compared to VOL + PROP (11% vs 24%, P = 0.002), and VOL + PROP + DEX fewer compared to VOL + PROP (16% vs 24%, P = 0.023). This differential effect was limited to PACU stay; antiemetic use increased across all groups following PACU discharge until midnight (ranging from 38–46% across groups, P = 0.71) and through the first postoperative day (ranging from 47–57%, P = 0.20). Conclusions The benefit associated with two PONV prevention strategies, the addition of dexmedetomidine infusion or avoidance of opioid and volatile anesthetics, did not persist after PACU discharge. These findings highlight the challenge of PONV on postoperative wards, and the need for a novel multimodal team approach to mitigate this complication.