Had a case yesterday that left me with 2 questions.
58/F, 65kg, ACDF 2 levels. h/o PONV. During our pre-op assessment she said that a patch behind her ear seemed to help for a prior surgery that was of shorter duration. So we put on the scop patch, but unfortunately, not until about 20min before beginning the surgery. I gave her 8mg of Dexamethasone as soon as the intubation & 2nd PIV & bair hugger etc was all complete, so as early on as I could. We intubated w/succs & used vec 3mg the first dose, then 1 mg thereafter trying to keep 2 twitches. She received nearly 2L RL during the case, which lasted just over 4 hours (room time). Had 925mL UOP, of not concentrated urine, so that seems to indicate she wasn't overly hypovolemic. While we were at lunch, she briefly (Looking back on the monitor, lasted maybe 1-2 min?) became brady to 33 & hypotensive. The CRNA covering us gave her 5mg of Epehdrine quickly followed by 0.2mg of glyco. We returned about 5min later & her BP was fine & HR was low 100s. HR drifted down to 80s during the remainder of the case. She had 4 twitches w/fade, so gave her 3mg neostigmine & another .4mg glyco. Also gave her 4mg ondansetron the last 30 min or so of the case. As we rolled into PACU she started vomiting clear, bile yellow liquid, & continued to do so the 15+ min we were in PACU.
So my questions:
First, what could we have done better to prevent her PONV? Besides get the scop patch on her the minute she walked into pre-op. I at first suspected the reversal, but then looked at several studies that did not support the thought that Neostigmine w/glyco contribute to PONV. As a side note, I've seen repeatedly in the lit that ondansetron works better once Pt's have emesis, not so much at prevention of N/V, yet in the two clinical sites I've been to thus far, it's always given at the end of the case & phenergan is reserved for the PACU. Thoughts?

Second, I was wondering if the bradycardia was from the surgeons manipulating the RLN, which branches off the vagus. Thoughts?

Thanks!