Multimodal prevention of pain, nausea and vomiting after breast cancer surgery

Background. Despite many one- or two-modal attempts to relieve postoperative nausea and vomiting (PONV) and pain, postoperative issues following breast cancer surgery remain a substantial problem. Therefore, the aim of this explorative, hypothesis-generating study was to evaluate the effect of a multimodal, opiate-sparing, evidence-based regimen for prevention of PONV and pain. Methods. Two hundred consecutive patients scheduled for breast cancer surgery were included. The prevention regimen included a package consisting of preoperative paracetamol, dextromethorphan, celecoxib, gabapentin, dexamethasone, total intravenous anaesthesia and intraoperative ondansetron. The patients were prospectively scored according to PONV, pain during rest and mobilization and major side effects. Results. Of 200 consecutive breast cancer patients, 191 received the full package. During the first 36 postoperative hours, 79.1% reported no PONV at all and only 3.7% reported severe PONV Arrest, 69.6% reported no or light pain and 3.1% reported severe pain, with corresponding values of 59.7% and 8.9% during arm mobilization. Mean postoperative morphine consumption was 2.2 mg. The only significant side effect was transient dizziness. Conclusion. A multimodal, opiate-sparing regimen to prevent pain and PONV seems to be more effective than one-or two-component regimens on PONV and pain after breast cancer surgery, a result which calls for large-scale multicenter or randomized studies. (Minerva Anestesiol 2010;76:805-13)