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August, 2000
Anesthesiology

Nonopioid Analgesia Improves Outcomes
Pgs 582-3

To the Editor:

The recent article by Greif et al.,1 highlighted in The New York Times Science section on November 9, 1999, published a reduction in postoperative nausea and vomiting (PONV) ragte of 30% to 17% using supplemental postoperative oxygen. Although this would appear to be an impressive improvement, both of these rates fall well within the 15-40% PONV rate usually cited for this problem. The anesthetic regimen included the routine use of optioids in the form of 1-3 mg/kg fentanyl during induction, and more for maintenance.

Macario et al.2 confirmed the primacy in patients' perspective of the avoidance of PONV. Tang et al.3 recently published an article regarding the superiority of nonoptioid analgesia using local anesthesia instead of opioids for reducing PONV and for greater patent satisfaction. Ponnudurai et al.4 recently published an article regarding the superiority of ketamine plus local anesthesia versus alfentanil for pain relief and for ambulation.

Any study about PONV that includes the routine use of optioids may be trying to get the right answer by asking the wrong question. Avoiding the routing use of optioids, Friedberg 5,6 recently published a 0.6% PONV rate in a series of 1,264 patients, one third of whom had PONV with the use of previous opioid-based anesthetics. Was Pogo right after all? Have we met the enemy, and it is us?

Barry L; Friedberg, MD
Clinical Instructor in Anesthesia
University of Southern California
Corona del Mar, California
narkose@home.net

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1. Greif R, Laciny S, Rapf B, Hinkle RS, Sessler DI: Supplemental oxygen reduces the incidence of postoperative nausea and vomiting, Anesthesiology 1999, 91:1246-52
2. Macario A, Weinger M, Carney S, Kin A; Which clinical outcomes are important to avoid? The perspective of patients, Anesth Analg 1999;89:652-8
3. Tang J, Chen I, White PF, Watcha MF, Wender RH, Naruse R, Karinger R, Slominsky A; Recovery profile costa and patient satisfaction with propofol and sevoflurance for fast track office-based anesthesia. Anesthesiology 1999; 91:253-61
4. Ponnudurai R, Yu CW, Reyes A, Wu He; A comparison of the preemptive effect of ketamine and alfentanil on the postoperative pain in patients undergoing abdominal hysterectomy while under general anesthesia; Am J Anesthesiol 1999; 89-1589
5. Friedberg BL; Another perspective on PONV (letter), Anesth Analg 1999, 89; 1589
6. Friedberg BL; Propofol-ketamine technique, dissociative anesthesia for office surgery: A five-year review of 1,264 cases. Anes Plast Surg 1999; 23:70-5
   

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