Prophylaxis to prevent vasovagal reaction suggestion....

[pastafan]

I have a new patient, male 63y.o., that has a history of multiple vasovagal reactions with procedures such as ESI's, thyroid bx, etc. Robinul IV is effective but in office price would far exceed reimbursement for the mbb procedure. ( That pricing is ridiculous but another thread) I plan to give him PO xanax but has anyone ever used PO glycopyrrolate? What is the dose? Any other suggestions?

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[emd123]

My question is what are his actual symptoms?

The treatment for a vasovagal reaction is to lay someone down recumbent, wait and do nothing else. Meds aren't needed, and meds do nothing. If there's anxiety, fine. Xanax. But technically that's anxiety that you're treating.

If it's anything more than a brief, self limited episode that resolves on it's own by having a patient lay down for a few minutes, then by definition it's not vagal (or neurocardiogenic syncope, pick a term). In a 60 + old male I'd wonder about indiagnosed cardiac stuff.

But if it's truly vagal? Do the procedure. Roll them onto their back, maybe a little head-down trendelenburg, wet towel on head and have them lay there as long as they need.

By definition: if it's vagal, you don't have to worry. At all. Lie them down and observe. Make sure they have a driver!

If your worried, then why are you? Maybe they have something undiagnosed cardiac and no bandaid med like glycopyrolate is going to prevent badness. If so, they need to see cards and get their AICD/pacer and not be bradying down to 20 beats per minute during your CESI.

My advice: ask this exact question to his cardiologist and document.

 

[Jitter Bug]

Agree, don't start using flashy meds overcome something that only lasts like 7 minutes. Just make sure he has had a good cardiac workup before you see him, based on his history. Then if all good, deal with the anxiety: elevating the feet, cool washcloth on the forehead, extra staff member just to hand hold and talk to the guy.

 

[pastafan]

Interesting. Cardiac w/u for mbb when ACC doesn't recommend w/u for anything short of major surgery? He has never had any cardiac sx except for these procedures. It sounds like needle phobia gone bad, not zebras. If he had bradycardia to 20's he would have been worked up already but that does not appear to be the case. I suppose I could send him to cardiologist but ACC guidelines would preclude much of a workup.

 

[emd123]

What are his symptoms? Fainting, bradycardia? Or just gets a little weak and dizzy and panics? There's a big difference.

Also, who declared "it's only vagal"? Cards? Primary care? The patient?

"Vasovagal" means different things to different people.

It's probably not a big deal, I'm just saying. "Vagal" in 18 year old female hardly is ever anything serious (unless it's IHSS, something congenital etc). "Vagal" in 60+ year old male could be nothing. Or it could be 10 other things that are cardiac.

Just saying, there's not enough detail here on this thread to know. Probably nothing...

but.....

 

[clubdeac]

I've given a little atropine before before procedures for patients like this or 1-2mg versed or valium 10mg po. Agree with cardiac w/u though

 

[Gauss]

http://www.gomerblog.com/2014/06/needles/

Developing: Patient Professes “Deep Hatred of Needles”

RENO, NV – Gomerblog was first on the scene at a preoperative holding bay outside of the main OR, where a patient about to undergo surgery made a fascinating proclamation. Gomerblog was investigating a recent allegation of an Anesthesiologist sneaking into patient’s rooms the morning of scheduled surgery and feeding them in order to delay or cancel their surgery. It was during this investigation that we “stumbled” across a new story.

“Doc, I hate needles”

Patient, R.K., was about to undergo an arthoscopic ankle surgery when upon greeting his anesthesiologist proclaimed, “Doc, I hate needles.” Fortunately our audio was running at the time to catch this earth shattering claim against sharp metal objects made to penetrate the human skin and sink into a blood filled vessel.

“I have never heard anything like this before,” said operating room nurse Billy Sharon, whose very creative friends call him B.S. “Most people come in here either not saying anything or at least saying they absolutely love needles and IVs. To hear someone go the other direction was a once in a lifetime experience.”

Early reports state the patient R.K. has 35% of his body surface area covered in tattoos, most likely placed by an unknown technique which doesn’t use needles.

 

[ctts]

Regarding vasovagal prevention... Not sure if this is evidence based, but I feel like fasting before procedure makes it more likely to occur. Since I saw an article not too long ago in Pain Physician which seems to suggest that fasting is not necessary for office based injection procedures, I have stopped having my patients fast. They are happier for it anyway. I did not have a high incidence of vasovagal to begin with, so not sure if it has made a difference, but subjectively, I feel like it has been less frequent since we stopped having patients fast.

 

[emd123]

Regarding vasovagal prevention... Not sure if this is evidence based, but I feel like fasting before procedure makes it more likely to occur. Since I saw an article not too long ago in Pain Physician which seems to suggest that fasting is not necessary for office based injection procedures, I have stopped having my patients fast. They are happier for it anyway. I did not have a high incidence of vasovagal to begin with, so not sure if it has made a difference, but subjectively, I feel like it has been less frequent since we stopped having patients fast.

I agree.