A New Protocol To Prevent Blowing Chunks

[jetproppilot]

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Thinking of establishing an aggressive post-operative-nausea-vomiting (PONV) protocol that every patient gets.

PONV is one of the most elusive enigmas in our biz that causes our patients alotta heartache and misery.

I'd personally rather eat a beetle, crunchy part and all, than worship the porcelain god. Hell the beetle is all protein, I'm into the bodybuilding culture....You get the gig...

btw you can eat bugs at the New Orleans Insectarium if you want....thought you might wanna know that...

Not in the mood for an arduous literature review so I'll just ask you studs, which is probably more accurate and real-life applicable anyway 🙂laugh🙂

Whatcha think about prophylactically hitting every receptor in the homo sapien species that even THOUGHT about being associated with nausea?

Every single time?

Every patient that has general anesthesia.

Alotta the literature in this arena is concerned with cost.

Let's assume cost isn't an issue and you wanted to give a drug in the appropriate dose to prophylactically shun post operative nausea.....not just one drug tho...since one drug can't do the job....

A BUNCHA DRUGS. To hit EVERY receptor. Do you know the nausea receptors, all of them, and what drug is specific for that receptor in the anti nausea mill eau?

Ondansetron+decadron+promethazine+........................

What else? Scopolamine? Atropine? Benadryl?

What else?

What doses of the less-used anti emetics if used for PONV prophylaxis?

What would be your PERFECT COCKTAIL???????

 

[Yo GabbaPentin]

Thinking of establishing an aggressive post-operative-nausea-vomiting (PONV) protocol that every patient gets.

PONV is one of the most elusive enigmas in our biz that causes our patients alotta heartache and misery.

I'd personally rather eat a beetle, crunchy part and all, than worship the porcelain god.

Not in the mood for an arduous literature review so I'll just ask you studs, which is probably more accurate and real-life applicable anyway 🙂laugh🙂

Whatcha think about prophylactically hitting every receptor in the homo sapien species that even THOUGHT about being associated with nausea?

Every single time?

Every patient that has general anesthesia.

Alotta the literature in this arena is concerned with cost.

Let's assume cost isn't an issue and you wanted to give a drug in the appropriate dose to prophylactically shun post operative nausea.....not just one drug tho...since one drug can't do the job....

A BUNCHA DRUGS. To hit EVERY receptor. Do you know the nausea receptors, all of them, and what drug is specific for that receptor in the anti nausea mill eau?

Ondansetron+decadron+promethazine+........................

What else? Scopolamine? Atropine? Benadryl?

What else?

What doses of the less-used anti emetics if used for PONV prophylaxis?

Scopolamine patch EARLY, maybe add some propofol to the list if it's not in short supply at the time. Everyone gets some decadron and zofran, but those with a hx get the scop patch.

 

[jetproppilot]

Scopolamine patch EARLY, maybe add some propofol to the list if it's not in short supply at the time. Everyone gets some decadron and zofran, but those with a hx get the scop patch.

Not concerned with targeting just patients wittha history....

...every patient that has a history of PONV had to blow chunks for the very first time, right?

What if we were really aggressive EVERY TIME? with our attention to detail? Could we prevent alotta first timers?

Dude/Dudette, MY MOM could've given me your answer.👎

And she works in a school cafeteria.

C'mon man! you can do better than that!!!!

Think outside the box of what every poster that practices anesthesia on here does.

 

[PMPMD]

If they have a serious h/o PONV and the case is going to be 2+ hours, I'll give droperidol. The black box warning states you have to monitor the EKG for 2-3 hours after dosing, so they will be monitored 2h in the OR plus 1h in PACU. (just to CYA medicolegally, I don't actually believe droperidol is a serious pro-arrhythmic).

The SAMBA PONV guidelines stated that drop was the most effective antiemetic, and would have been their #1 choice if not for the (bogus IMO) black box warning.

 

[PMPMD]

whoops, didn't see your last post Jet.

 

[lord_jeebus]

We use aprepitant preop for high-risk patients and it works really well. If cost was no object, I'd love to use it for almost everyone. I'd self-prescribe it if I needed GA.

 

[PMPMD]

Think I've got it - thanks lordjeebus

Preop:
Aprepitant
Scop patch
Droperidol
Pack of Marlboros (smokers have decreased incidence of PONV)

Intraop:
Zofran
Decadron
Propofol gtt
IM Ephedrine (the evidence is poor, but we're going for all receptors here)

Postop:
Phenergan
Benadryl - with these last 2 on board, they will be to drowsy to notice if they're nauseated.

 

[btbam]

Do people really give Atropine for PONV?

 

[jetproppilot]

Think I've got it - thanks lordjeebus

Preop:
Aprepitant
Scop patch
Droperidol
Pack of Marlboros (smokers have decreased incidence of PONV)

Intraop:
Zofran
Decadron
Propofol gtt
IM Ephedrine (the evidence is poor, but we're going for all receptors here)

Postop:
Phenergan
Benadryl - with these last 2 on board, they will be to drowsy to notice if they're nauseated.

Pat,

Now THAT'S A #$*ING AWESOME REPLY.

Thanks for raising the standard.

Moving on,

WRITE SOME STANDING ORDERS. That you would want if you were king, calling the shots, obliterating EVERY possible nausea possibility out there, using your vast cerebral pharmacologic armamentarium.

PatDaddy started it.

Anybody wanna be more specific?

 

[MRW]

zofran
reglan
dexamethasone
diphenhydramine
scopolamine
droperidol
propofol
phenergan
fosaprepitant
no opiods
also, I suppose a few weeks of nicotine patches preop and weaning of drugs that have N&V as side effects.

edit:
doh!
left my desk and came back to finish my post and got pre-empted...

 

[IlDestriero]

30cc/kg LR was shown to be an effective antiemetic in peds T&As. Tank 'em up too.
And don't forget acupressure at P6! As long as JPP is channeling the force, he can channel some ch'i as well.
Don't forget about the "minimally invasive anesthesia" Dr. Nutter.

 

[btbam]

5-HT3 Antagonists Alosetron • Azasetron • Bemesetron • Cilansetron • Clozapine • Dazopride • Dolasetron • Granisetron • Lerisetron • Metoclopramide • Mianserin • Mirtazapine • Olanzapine • Ondansetron • Palonosetron • Ramosetron • Ricasetron • Tropisetron • Zatosetron

CB1 Agonists (Cannabinoids) Dronabinol • Nabilone • Nonabine

D2/D3 Antagonists Alizapride • Bromopride • Chlorpromazine • Clebopride • Domperidone • Haloperidol • Itopride • Metoclopramide • Metopimazine • Prochlorperazine • Thiethylperazine

H1 Antagonists (Antihistamines) Cyclizine • Dimenhydrinate • Diphenhydramine • Meclozine • Promethazine

mACh Antagonists (Anticholinergics) Atropine • Hyoscyamine • Scopolamine

NK1 Antagonists Aprepitant • Casopitant • Ezlopitant • Fosaprepitant • Maropitant • Vestipitant

Others Cerium oxalate • Dexamethasone • Lorazepam • Midazolam • Propofol • Trimethobenzamide

 

[sevo85288]

zofran
reglan
dexamethasone
diphenhydramine
scopolamine
droperidol
propofol
phenergan
fosaprepitant
no opiods
also, I suppose a few weeks of nicotine patches preop and weaning of drugs that have N&V as side effects.

edit:
doh!
left my desk and came back to finish my post and got pre-empted...

Good list. But there is no evidence Reglan help prevent PONV. Diphenhydramine too.

 

[IlDestriero]

When Jet starts handing out blunts in holding, business is going to EXPLODE. One for the road too, OK Cheech.

 

[lord_jeebus]

When Jet starts handing out blunts in holding, business is going to EXPLODE. One for the road too, OK Cheech.

Please, we are anesthesiologists here, not some FM-trained medical marijuana clinic docs trying to make a quick buck.

We would administer it by vaporizer.

 

[Arch Guillotti]

 

[ssmallz]

One thing no one mentioned is hydration. I know the evidence is shaky at best but running in a liter or 2 into a healthy pt may help a bit. I know fluids always help my stomach when i'm sufferin from a hangover

 

[IlDestriero]

One thing no one mentioned is hydration. I know the evidence is shaky at best but running in a liter or 2 into a healthy pt may help a bit. I know fluids always help my stomach when i'm sufferin from a hangover

You hung over now?😴 post 11 is linked below.

30cc/kg LR was shown to be an effective antiemetic in peds T&As. Tank 'em up too.

Charlie Cote at MGH did the study.

 

[jetproppilot]

When Jet starts handing out blunts in holding, business is going to EXPLODE. One for the road too, OK Cheech.

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHA!!!!!!!


dude you may be on to something there....

 

[jetproppilot]

Arch,

please send me the dude in the pic's CV.

Tell him I'll give him full partnership from day 1, NO BUY IN.

My cell phone number is (504)-867-5309.

 

[Jay K]

As long as there are no contraindications, I'm partial, after induction, to administering metoclopramide, ondansetron and dexamethasone.

As to the effects of metoclopramide, aside from anecdotal post-op success in limiting PONV, I've witnessed profound gastric emptying and physical diminution of the stomach itself via EGD. It was actually quite surprising to see the stomach's reaction (vs small intestine prokinetic motility).

 

[Idiopathic]

As long as there are no contraindications, I'm partial, after induction, to administering metoclopramide, ondansetron and dexamethasone.

As to the effects of metoclopramide, aside from anecdotal post-op success in limiting PONV, I've witnessed profound gastric emptying and physical diminution of the stomach itself via EGD. It was actually quite surprising to see the stomach's reaction (vs small intestine prokinetic motility).

and whats the relationship of this to PONV? you dont need a full stomach to be nauseated/vomit and a hyperactive intestinal tract could actually be worse

 

[Endee]

and whats the relationship of this to PONV? you dont need a full stomach to be nauseated/vomit and a hyperactive intestinal tract could actually be worse

Tell me about it, I had dry heaves every single morning for 3 weeks when I started teaching 12th grade right out of college.

 

[Jay K]

and whats the relationship of this to PONV? you dont need a full stomach to be nauseated/vomit and a hyperactive intestinal tract could actually be worse

True

And I mentioned the gastric emptying as an interesting aside I've witnessed via EGD. I'm not suggesting it's the mechanism by which it is an anti-emetic; I'm sure you know the pharmacology behind metoclopramide. Please read my sentence again...

 

[desflurane]

Metoclopramide does not work for ponv regardless of what PACU nurses think. What it does will is cause dystonic reactions. Off the list.

I give em all I got and depending where I am working that involves:

IV hydration
Dex after induction
5HT du jour 15 min prior to emergence
TIVA if more than 2 risk factors
Drop or haldol if in my cart
NK1 preop if available
Scop patch- I'm not convinced the evidence is good. Rep fed us lunch gave us a copy of a crappy underpowered paper done by crnas. If young and healthy then maybe.

Limit opiods

Don't have access to a bong in the or (would be nice at times)

If all the above don't work (rare) and I need a rescue... 15mg prop and I'm a hero.

 

[periopdoc]

Scopalamine sucks. Tried it once on a long passage. I was nauseous for 12 days before it dawned on me that this was the first time I tried a scop patch. Pulled it off and was cooking Thai food 8 hours later.

Thought it was supratentorial so a few months later I slapped another one on at my house. Within three hours I was worshipping at the porcelain throne. Anecdotal as hell and it still could be supratentorial, but I am a bit more cautious about scop patches since then

Always thought that something that causes the muscles of my gut to contract (Reglan) would make me feel nauseous. Maybe I am wrong, but spasming gut doesn't sound too pleasant to me.


- pod

 

[Jay K]

Metoclopramide...What it does will is cause dystonic reactions.

True... I give it after induction so as not to "disturb" the patient.

As an aside, tardive dyskinesia is related to chronic or high-dose use, so not an issue related to single-dose 10mg intraop use. [Lest you get "touchy," I know you didn't mention tardive dyskinesia.]

Again, my success with metoclopramide, aside from what is suggested by its pharmacology, is in combination with other medications and anecdotal. Additionally, I didn't earlier preface that this regimen is typically reserved for adult patients. Pediatric patients tend to get dexamethasone and ondansetron.

I find PeriopDoc's anecdotal paradoxical reactions to scopolamine very interesting, since our practice tends to apply scopolamine patches in addition to other meds as part of the "everything and the kitchen sink" for those with significant PONV history.

 

[kmurp]

There was an article about using a nerve stimulator set to go off every 1 or 5 seconds with the electrodes over the P6 accupressure point that was written a number of years ago.
Other than that: focus on the higher risk groups that are well known. Each receptor specific drug lowers relative risk 25%. Scop only for patients with a history of N&V AND motion sickness (it has side effects, as you know. Emend ONLY for patients with a serious history as an additive to the above. At least 1 liter IVF for all outpatients. TIVA only for patients with a strong history who are having surgery that you think you can get away with minimal narcotics. And of course, regional anesthesia where possible.

 

[Idiopathic]

yeah i think there was an article showing how using the nerve stimulator on the median nerve rather than the ulnar nerve would lessen PONV

 

[pgg]

yeah i think there was an article showing how using the nerve stimulator on the median nerve rather than the ulnar nerve would lessen PONV

I think it was on the cover of A&A 2 or 3 years ago.

There's another article about it in this month's A&A (I haven't read it yet).

 

[periopdoc]

Anyone else think it sad how little evidence based thins thread has become. You won't use a scop patch on patient because it made YOU hurl? That's how crnas practice. Do whatever Tong Gan says:

http://www.thesotos.net/anesthesia/pearls/ponvreview.pdf

Great, a thread aimed at developing a antiemetic prophylaxis protocol for all comers which has posts discussing, among other things, handing out doobies in preop/ PACU, and I get MY balls busted for urging caution that including certain medications in a protocol for all comers may result in some idiosyncratic reactions like mine and, contrary to the OP's intentions, may not do everyone a favor... and you can't even bust my balls in the correct thread.


From the guidelines that you linked to (a copy of which, ironically enough, was placed in all of our anesthesiologist's mailboxes by one of our senior partners on Mar 16th)

The panel agreed that not all patients should receive PONV prophylaxis. In general, patients at small risk for PONV are unlikely to benefit from prophylaxis and would be put at unnecessary risk from the potential side effects of antiemetics. Thus, prophylaxis should be reserved for those patients at moderate to high risk for PONV.

Now who's cooking with evidence? *

I never said that I don't use scopolamine patches, I just urged caution on the part of those who are developing a protocol for all comers.

There is good evidence for treatment options, including scopolamine, for patients with significant risk factors. I will use it when the situation is appropriate (young patient with significant risk factors where the case is longer than three hours or I can place the patch the night before). Occasionally I will even place it for short procedures for the purpose of post-discharge TX understanding that I will derive no benefit during a brief PACU stay.

There is old evidence on the cost effectiveness of tailoring your antiemetic prophylaxis to those who have risk factors. As all of these medications have become cheaper, the current economics may actually favor the approach theorized by Jet. However, as of yet, we have no evidence to support that idea.

I conjecture that using medications with the best side effect profiles is likely to work in our favor. Even among those with significant risk factors the NNT is on the order of 5-10 with the NNH ranging from 6-50 depending on the drug/ side effect studied. Therefore, it behooves us to consider potential side effects when developing a non-tailored approach to PONV with the goal of minimizing PONV and maximizing throughput and patient satisfaction.


If I was to suggest a protocol for all comers it would look something like this.

1 - Minimize opiates by utilizing other analgesic modalities
2 - Minimize non-depolarizers ergo neostigmine.
3 - Minimize volatile inhaled anesthetics

Preop
1 - Tylenol PO or IV
2 - Celebrex
3 - Regional analgesia/ anesthesia where appropriate

Peri-induction
1 - Ketamine 0.5 mg/kg +/- low dose infusion
2 - Decadron
3 - Droperidol 0.625 mg
4 - Nerve stim on median nerve
5 - Hydration

15 min before case ending
1 - Zofran
2 - Repeat decadron

Post-op rescue
- Repeat Zofran q 15 min x2
- Phenergan
- IM ephedrine if hypotensive/ borderline hypotensive
- Repeat droperidol once and monitor for one hour.
- other therapies as indicated

- pod

* Disclaimer - I am fully aware that consensus opinions/ statements are not exactly evidence, please allow me some hyperbole.

 

[deleted9493]

Droperidol is an amazing rescue drug for the sensation of nausea. You really think that you'll be monitoring for QT prolongation with a 5 lead in the OR? Torsades, yes...interval lengthening not so much.

 

[periopdoc]

Setting aside the fact that monitoring for QT prolongation after the doses of droperidol that we use is completely medically un-necessary, and is only done for legal reasons...

Are you arguing that (using the same 3-5 lead monitoring scheme) it is somehow easier for a PACU nurse (caring for 2 or more patients) to recognize QT prolongation than it is for a physician/ CRNA who is caring for a single patient in the OR? Or are you getting consecutive 12-lead EKGs and reviewing them while caring for the next patient?

I am not sure that I see your point.

- pod

 

[deleted9493]

Setting aside the fact that monitoring for QT prolongation after the doses of droperidol that we use is completely medically un-necessary, and is only done for legal reasons...

Are you arguing that (using the same 3-5 lead monitoring scheme) it is somehow easier for a PACU nurse (caring for 2 or more patients) to recognize QT prolongation than it is for a physician/ CRNA who is caring for a single patient in the OR? Or are you getting consecutive 12-lead EKGs and reviewing them while caring for the next patient?

I am not sure that I see your point.

- pod

Nope, just saying that real time ECG monitoring with a 3 or 5 lead setup is not a sensitive means of detecting QT prolongation clinically. We should be saying that we're monitoring for polym. v-tach, though its cause is in fact interval prolongation. That's all.

Agreed re: it's unnecessary monitoring.

 

[fakin' the funk]

Other than that: focus on the higher risk groups that are well known. Each receptor specific drug lowers relative risk 25%. Scop only for patients with a history of N&V AND motion sickness (it has side effects, as you know.

Thank you for injecting some assessment of risk/benefit here.

Jet's original post seems to imply that we should treat all patients the same since preventing PONV is highly desirable.

But patients have different levels of risk and therefore stand to benefit differently from our interventions.

Just throwing every drug from our "vast cerebral armamentarium" at every patient a) is mindless, and b) subjects many patients to the RISKS of these drugs while providing little to no BENEFIT.

Imagine giving someone with NO risk factors for PONV the "kitchen sink" protocols described below. That's a huge waste of money first of all and it probably provides no benefit to that patient.

 

[fakin' the funk]

Thinking of establishing an aggressive post-operative-nausea-vomiting (PONV) protocol that every patient gets.

It's the "every patient" part you've got wrong here.

Just develop a protocol based on the known risk factors. Apfel's 4-RF system has been around for 10+ years. If it was me, I would do something like this:

1 risk factor - 1 intervention (ondansetron)
2 - ondansetron + dexamethasone
3 - ondansetron + dexamethasone + po aprepitant; try to eliminate opioids altogether with ketorolac, APAP, regional
4 - ondansetron + dexamethasone + po aprepitant + TIVA; try to eliminate opioids altogether with ketorolac, APAP, regional

** if diabetic, substitute droperidol for dexamethasone
** if monitoring available, substitute droperidol for any of the above
** may substitute anticholinergic for inner ear or eyeball cases

 

[Idiopathic]

It's the "every patient" part you've got wrong here.

Just develop a protocol based on the known risk factors. Apfel's 4-RF system has been around for 10+ years. If it was me, I would do something like this:

1 risk factor - 1 intervention (ondansetron)
2 - ondansetron + dexamethasone
3 - ondansetron + dexamethasone + po aprepitant; try to eliminate opioids altogether with ketorolac, APAP, regional
4 - ondansetron + dexamethasone + po aprepitant + TIVA; try to eliminate opioids altogether with ketorolac, APAP, regional

** if diabetic, substitute droperidol for dexamethasone
** if monitoring available, substitute droperidol for any of the above
** may substitute anticholinergic for inner ear or eyeball cases

with that, you still are going to fail in 15-20% of patients in the high risk group...it doesnt seem like we have the magic bullet yet

 

[dhb]

with that, you still are going to fail in 15-20% of patients in the high risk group...it doesnt seem like we have the magic bullet yet

At a hospital where everybody uses a similar scale very rarely do you have someone with PONV in the pacu...

A good trick that hasn't been mentionned but is not really suitable for quick outpatient surgery turnover is a propofol PCA: 10mg a pop 👍

 

[Idiopathic]

At a hospital where everybody uses a similar scale very rarely do you have someone with PONV in the pacu...

A good trick that hasn't been mentionned but is not really suitable for quick outpatient surgery turnover is a propofol PCA: 10mg a pop 👍

no, my point is that in the true high risk 4-intervention patient you will still have >15% of those patients with PONV regardless of number of standard interventions. not suggesting that applies to all comers.

 

[periopdoc]

15% seems awfully high. Of my high risk patients in the last 6 months, 1 was nauseous post-op and I am convinced that it is because I overdosed her demerol (the pyxis gave me two doses instead of one and I tried to get away with giving it despite my better judgement.)

The last one I did had a LONG history of PONV with admissions for intractable PONV. She was getting a laparoscopic gyn surgery that was going to be about 1 hour. After talking with her, I was convinced that it was the volatile that was getting to her and she didn't actually have a problem with opiates (although she couldn't separate the two in her mind.)

Sux, ETT, Propofol GTT, 70% Nitrous (Sacrilege I know), Ketamine 0.5 mg/kg and Ketorolac 30mg with induction, Esmolol for BP and HR control, demerol for the wakeup. Dexamethasone, droperidol, zofran, hydration. Patient woke up, felt great, and wants me to do any further anesthetics.

I don't think that I am particularly good or lucky, I think rates in the low-mid single digits are obtainable even in high risk patients given proper consideration of what the actual trigger is. For some it is volatiles, for some it is opiates, for some it is nitrous.

- pod

 

[Idiopathic]

15% seems awfully high. Of my high risk patients in the last 6 months, 1 was nauseous post-op and I am convinced that it is because I overdosed her demerol (the pyxis gave me two doses instead of one and I tried to get away with giving it despite my better judgement.)

The last one I did had a LONG history of PONV with admissions for intractable PONV. She was getting a laparoscopic gyn surgery that was going to be about 1 hour. After talking with her, I was convinced that it was the volatile that was getting to her and she didn't actually have a problem with opiates (although she couldn't separate the two in her mind.)

Sux, ETT, Propofol GTT, 70% Nitrous (Sacrilege I know), Ketamine 0.5 mg/kg and Ketorolac 30mg with induction, Esmolol for BP and HR control, demerol for the wakeup. Dexamethasone, droperidol, zofran, hydration. Patient woke up, felt great, and wants me to do any further anesthetics.

I don't think that I am particularly good or lucky, I think rates in the low-mid single digits are obtainable even in high risk patients given proper consideration of what the actual trigger is. For some it is volatiles, for some it is opiates, for some it is nitrous.

- pod

i dont understand why you used N2O on that patient...probably the worst thing you can do for PONV and thats probably the highest risk patient you could have...so id say you got lucky

heres the paper that quotes 10-15% rates of PONV in patients receiving 3+ antiemetics.

http://www.ncbi.nlm.nih.gov/pubmed/18633023

 

[periopdoc]

I do not believe that nitrous is ubiquitously emetogenic. I know not everyone agrees with me on this, but I also know that I am not the only one who feels this way.

In fact, the only time I use nitrous is for patients who have had significant PONV and in whom I believe that nitrous was not a trigger for them.

I wouldn't typically use nitrous for laparoscopy, but this case had minimal insufflation time (~30 minutes) with another 30-45 min after exsufflation where they were working transvaginally.

This was the patients 6th or 7th surgery, with every previous surgery resulting in long PACU stays or admissions for PONV so I don't think that I just got lucky. I had access to most of the previous records. Many things had been tried for her PONV including a propofol/ volatile anesthetic combination (we can only get the 20cc vials of propofol in this ASC so it is painful to do more than sedative dosing). The one common thread to all of her anesthetics was volatile inhaled.

I do believe that for some people, nitrous is emetogenic. For some people, any level of volatile inhaled is emetogenic. Clearly for some people any level of opiate is emetogenic. I also believe that if you can tease out some details of the patient's PONV and then tailor your anesthetic plan you can reduce your incidence of PONV. Tailoring your antiemetic prophylaxis (as was done in the paper you quoted) is only half the story. But then again, I could just be one lucky FOS SOB *****. No polls please

- pod

 

[Jay K]

But then again, I could just be one lucky FOS SOB *****.

"It's better to be lucky than good." [never gets old]

I consistently use 70% nitrous.

- Another lucky FOS SOB *****

 

[Apollyon]

The last one I did had a LONG history of PONV with admissions for intractable PONV.

Just a one-minute derail, but this hearkens back a bit to anesthesiologists admitting patients. It was stated that MH belongs to anesthesia exclusively, and those patients go to the unit. Who admits intractable PONV? Who manages them? Is it primary care (IM/FM), or the surgical service that operated, with anesthesia consult? I can't imagine PONV going to the unit, unless the pt aspirated.

Otherwise, I am avidly monitoring this thread for information on optimally treating my non-post op vomiters.

 

[periopdoc]

Primary surgical service. Mostly to ensure hydration and vital sign stability as they have already had the antiemetic kitchen sink thrown at them before they leave PACU. At that point only the ultimate antiemetic (tincture of time) will cure them.

- pod

 

[dhb]

I do not believe that nitrous is ubiquitously emetogenic.
- pod

I agree i've used nitrous enough without seeing a difference in PONV when prophylaxis is used.

 

[deleted9493]

15% seems awfully high. Of my high risk patients in the last 6 months, 1 was nauseous post-op and I am convinced that it is because I overdosed her demerol (the pyxis gave me two doses instead of one and I tried to get away with giving it despite my better judgement.)

The last one I did had a LONG history of PONV with admissions for intractable PONV. She was getting a laparoscopic gyn surgery that was going to be about 1 hour. After talking with her, I was convinced that it was the volatile that was getting to her and she didn't actually have a problem with opiates (although she couldn't separate the two in her mind.)

Sux, ETT, Propofol GTT, 70% Nitrous (Sacrilege I know), Ketamine 0.5 mg/kg and Ketorolac 30mg with induction, Esmolol for BP and HR control, demerol for the wakeup. Dexamethasone, droperidol, zofran, hydration. Patient woke up, felt great, and wants me to do any further anesthetics.

I don't think that I am particularly good or lucky, I think rates in the low-mid single digits are obtainable even in high risk patients given proper consideration of what the actual trigger is. For some it is volatiles, for some it is opiates, for some it is nitrous.

- pod

What does Nitrous add? Were you using it to speed emergence or as additional assurance of amnesia, in case of propofol under-dosing?
Just curious.

I'd just not be able to get over the concern that you're one bowel nick and electrocautery spark away from an intra-abdominal combustion on 70% nitrous. Unlikely, sure, but I've also watched nitrous preferentially dilatate small bowel in both open and closed intraabdominal cases on lower concentrations than that.

 

[dhb]

I'd just not be able to get over the concern that you're one bowel nick and electroca

Has this ever happened? A quick pubmed search with these terms revealed nothing: "combustion nitrous oxide laparoscopy"

A lot of people have a lot of beef with nitrous but i doubt they've ever used it. I love it in frail patient who won't tolerate 1 mac of volatile but will move at half mac. It's also a very good short acting analgesic in kids.

 

[deleted9493]

Has this ever happened? A quick pubmed search with these terms revealed nothing: "combustion nitrous oxide laparoscopy"

A lot of people have a lot of beef with nitrous but i doubt they've ever used it. I love it in frail patient who won't tolerate 1 mac of volatile but will move at half mac. It's also a very good short acting analgesic in kids.

http://journals.lww.com/anesthesiol..._Explosion_Hazards_with_Nitrous_Oxide.11.aspx

 

[Jay K]

http://journals.lww.com/anesthesiol..._Explosion_Hazards_with_Nitrous_Oxide.11.aspx

Interesting link hudsontc.

So, it's theoretically possible given a perfect storm of conditions - maximal methane and/or hydrogen, bowel perforation, sufficient nitrous concentration in the peritoneal cavity and an ignition source, but no reported cases to anybody's knowledge?