"Albuterol Resp Treatment On Admit"

[jetproppilot]

Advertisement - Members don't see this ad

Preopped a day-surg pt the other day for a gyn procedure (LEEP).

19 year old with a history of asthma...well controlled...no hospitalizations in the last 5 years...thin, active, otherwise healthy. No wheezing on AM of surgery. Hasnt used her inhaler in the last 2 weeks.

OB GYN docs day surgery admit orders at the bottom said "Ventolin Tx On Admit".

New OB GYN doc I've never worked with before.

I only give pre-op bronchodilators if pt has clinical manifestations.

Does anyone prophylax well controlled (non-wheezing) asthmatics with a resp tx before surgery?

And if so, why?

I'm not aware of any studies showing prophylactic, preoperative administration of inhaled selective B2s decreases perioperative exacerbation of known reactive airway disease. If there is one, please give me a link to it.

 

[The_Sensei]

... If there is one, please give me a link to it.

No can do Mr. J. That's because there is none. You need to have a little chat with the new kid in town and let him know that a knee jerk reaction to anyone saying "I have asthma" and a concomitant order for an Albuterol treatment is unnecessary. If for some bizarre reason he does not acquiese, at least hook the unsuspecting party up with a Xopenex neb. to minimize the tachycardia, etc. in an already more than likely anxious patient.

 

[militarymd]

Absolutely no reason to give a medication that is otherwise not needed just because you're going to put someone to sleep.


I agree with J completely.

I constantly see inexperienced anesthesiologists who constantly give unnecessary medications preop to "minimize" complications/lawsuits.....they make me laugh....except when I have to work with them....

The top meds given unnecessarily in no particular order:

albuterol
reglan
pepcid
bicitra
versed

Top tests ordered unnecessarily ..now that I'm on a roll..again in no particular order:

chem 7
cxr
ecg
pt/ptt
cbc
platelet function study

 

[Annette]

Xopenex is marketed with "less tachycardia", but in reality it only increases HR by~2 beats/min less than albuterol.

 

[jetproppilot]

The top meds given unnecessarily in no particular order:

albuterol
reglan
pepcid
bicitra
versed

Top tests ordered unnecessarily ..now that I'm on a roll..again in no particular order:

chem 7
cxr
ecg
pt/ptt
cbc
platelet function study

HAHAHHAHAHAHAHAHAHAHAHAHAHAHHAHAHAHAHAHAHAH

Mil,

Jet gives a HELL YEAH

for all the needless, voodoo B.S. performed on a daily basis for only-god-knows-why.

1)Why do we give parturients bicitra before an epidural? Oh, sorry, I know.

So if their nausea isnt bad enough from the pregnancy process, we can be sure they throw up.

2)Why do we give asymptomatic asthmatics an albuterol tx before their surgery? Oh, sorry, I know.

Because they have asthma.

3)Why do we give a patient with "GERD" reglan and pepcid before their surgery? Oh sorry, I know.

Because they have "GERD".

4)Why do anesthesiolgists hold up a case on a patient with preoperative pulmonary disease (albeit optimized) until the CXR materializes? Oh, sorry, I know.

Because the patient has preoperative pulmonary disease.

5)And last, but most importantly,

WHY DO CLINICIANS, WITH TWELVE-PLUS YEARS OF TRAINING, RELINQUISH TAKING CARE OF PATIENTS IN AN EFFICIENT FASHION, WAITING FOR A LAB TEST THAT DOESNT REALLY MATTER????

I HAVEN'T THE FOGGIEST IDEA. BUT IT HAPPENS EVERY DAY.

"anesthesiologist": "Sorry, we can't go to the OR until I see the post dialysis K+."

"anesthesiologist": "Sorry, we can't go to the OR until I see the CXR on this asymptomatic asthmatic."

"anesthesiologist": "Sorry, we cant start the TAH on this 39 y/o healthy patient until her CBC comes back."

Go ahead and laugh.

Our "colleagues" do this s hit every day.

 

[sdn1977]

Xopenex is marketed with "less tachycardia", but in reality it only increases HR by~2 beats/min less than albuterol.

Until they pick it up at the pharmacy, realize it is considered non-formulary by their insurance company, which means it is now subject to the deductible & they must pay $100....then their HR increases by about 20 beats/min, they become tachypneic, start to wheeze & wish they had their old albuterol inhaler back & now really do need a tx!!! (only said in jest for those who feel Xopenex is superior!!!)

 

[toughlife]

Absolutely no reason to give a medication that is otherwise not needed just because you're going to put someone to sleep.


I agree with J completely.

I constantly see inexperienced anesthesiologists who constantly give unnecessary medications preop to "minimize" complications/lawsuits.....they make me laugh....except when I have to work with them....

The top meds given unnecessarily in no particular order:

albuterol
reglan
pepcid
bicitra
versed

Top tests ordered unnecessarily ..now that I'm on a roll..again in no particular order:

chem 7
cxr
ecg
pt/ptt
cbc
platelet function study

I have worked with attendings who give versed to every patient preop. And these were old attendings. Could this be regional?

 

[militarymd]

I have worked with attendings who give versed to every patient preop. And these were old attendings. Could this be regional?

20 years of flying a biplane don't make you F-22 raptor aviator.

 

[VentdependenT]

HAHAHHAHAHAHAHAHAHAHAHAHAHAHHAHAHAHAHAHAHAH

Mil,

Jet gives a HELL YEAH

for all the needless, voodoo B.S. performed on a daily basis for only-god-knows-why.

1)Why do we give parturients bicitra before an epidural? Oh, sorry, I know.

So if their nausea isnt bad enough from the pregnancy process, we can be sure they throw up.

2)Why do we give asymptomatic asthmatics an albuterol tx before their surgery? Oh, sorry, I know.

Because they have asthma.

3)Why do we give a patient with "GERD" reglan and pepcid before their surgery? Oh sorry, I know.

Because they have "GERD".

4)Why do anesthesiolgists hold up a case on a patient with preoperative pulmonary disease (albeit optimized) until the CXR materializes? Oh, sorry, I know.

Because the patient has preoperative pulmonary disease.

5)And last, but most importantly,

WHY DO CLINICIANS, WITH TWELVE-PLUS YEARS OF TRAINING, RELINQUISH TAKING CARE OF PATIENTS IN AN EFFICIENT FASHION, WAITING FOR A LAB TEST THAT DOESNT REALLY MATTER????

I HAVEN'T THE FOGGIEST IDEA. BUT IT HAPPENS EVERY DAY.

"anesthesiologist": "Sorry, we can't go to the OR until I see the post dialysis K+."

"anesthesiologist": "Sorry, we can't go to the OR until I see the CXR on this asymptomatic asthmatic."

"anesthesiologist": "Sorry, we cant start the TAH on this 39 y/o healthy patient until her CBC comes back."

Go ahead and laugh.

Our "colleagues" do this s hit every day.

Jet whaz wrong with giving some pepcid and reglan to a Gerdy?

You bastards always make me think....I'm was totally damn guilty of the albuterol thing until I was reprimanded. Albuterol is a RESCUE inhaler.

However what if someone has night time symptoms once a week and has to use the albuterol a couple of times a week while they are on advair (which they probably aren't using with any frequency). In other words, a poorly controlled asthmatic. Would you advocate slappen them with some albuterol/atrovent prior to induction? Or just hold off and get the ETT in and see how it goes?

Any poops, I do give atrovent to people with emphysema/bronchitis before surgery.

Much props to my role models on here.

Sorry bout my lack of posts but I've been damn busy. In the UNIT now and I just handed everyone a copy of the Surving Sepsis Campaign. Boooooooyaaahahahahahaha.

 

[toughlife]

20 years of flying a biplane don't make you F-22 raptor aviator.

Maybe it is regional.

 

[jetproppilot]

Jet whaz wrong with giving some pepcid and reglan to a Gerdy?

You bastards always make me think....I'm was totally damn guilty of the albuterol thing until I was reprimanded. Albuterol is a RESCUE inhaler.

However what if someone has night time symptoms once a week and has to use the albuterol a couple of times a week while they are on advair (which they probably aren't using with any frequency). In other words, a poorly controlled asthmatic. Would you advocate slappen them with some albuterol/atrovent prior to induction? Or just hold off and get the ETT in and see how it goes?

Any poops, I do give atrovent to people with emphysema/bronchitis before surgery.

Much props to my role models on here.

Sorry bout my lack of posts but I've been damn busy. In the UNIT now and I just handed everyone a copy of the Surving Sepsis Campaign. Boooooooyaaahahahahahaha.

Venty,

As Mil initially pointed out, and I seconded, we give WAY too many medicines unneedingly.

There is no literature (thanks Sensai) supporting prophylactic B2s in an asymptomatic asthmatic.

Concerning GERD, know what concerns me? Postural GERD. The dude thats taking PPIs and still gets the burning sensation when laying flat.

Those dudes wont get an LMA (say, for a knee scope). But I've identified only a few of them in ten years of practice.

GERD, in my book, well controlled, will get an LMA every time (when an LMA is appropriate). Its laughable that clinicians feel the need to do a rapid sequence induction, complete with the totally useless Selleck maneuver, on these patients.

And for you purists out there, please point me to evidence that shows the Selleck maneuver has any benefit.

If a dude takes a PPI for GERD, and is completely asymptomatic, there is no reason to give them Pepcid/reglan. And there is no need to avoid an LMA.

Challenged by an attending on this issue?

Ask them for data showing that asymptomatic GERD patients have an increased morbidity/mortality from aspiration by 1)not giving pepcid/reglan 2) using an LMA.

After your discussion with your attending, you will 1)stop giving so much pepcid/reglan 2)start using more LMAs.

And with all due respect to your intellectual-Venty-a ss, prophylactic Atrovent doesnt do anything either. Except take up more time, and potentially delay the case because the respiratory terrorist is busy somewhere else.

See evidence of bronchoconstriction pre-op? By all means be aggressive. See if you can ameliorate the symptoms to a point where you feel comfortable going forward.

Been aggressive pre-op and pt still has symptoms? Cancel the case. Very, very, very rare. But it happens.

Asymptomatic COPDer?

No need to give additional medicines.

Funny, how new anesthesiologists conjure what medicines they can give.

And how experienced anesthesiologists figure out how to do a case with as few medicines as possible.

 

[ThinkFast007]

Jet

about the Sellick Maneuver, I found this article, it looks like Dr. Salem (over at Illinois Masonic) is one of the authorities on this because he and Dr. Sellick advocated it's use (although apparently Dr. Sellick didnt even come up w/ the maneuver, it's been used by Munro in the 1700's....i know i'm a nerd...but i LOVE historical $hit)....at any rate, here's an article I found, w/ some interesting references (which unfortunately i couldnt pull up):

Cricoid Pressure Is Effective in Preventing Esophageal Regurgitation
[CORRESPONDENCE]
Neelakanta, Gundappa M.D.

David Geffen School of Medicine at University of California, Los Angeles. [email protected]
Support was provided solely from institutional and/or departmental sources.
(Accepted for publication February 27, 2003.)
To the Editor:—

Cricoid pressure (Sellick's maneuver) is a routinely used technique for the prevention of pulmonary aspiration of gastric contents during anesthesia in patients at high risk of aspiration. Its effectiveness in preventing regurgitation of esophageal contents has been demonstrated in several studies 1,2 and in cadavers. 3–5 However, its effectiveness in preventing aspiration in clinical practice is debated. 6 The following case scenario clearly demonstrates its effectiveness during clinical anesthesia.

A 21-yr-old, 75-kg man presented for repositioning of an intraocular lens under general anesthesia. He had a history of esophageal reconstruction by gastric pull-through to treat childhood achalasia. General anesthesia about 2 yr earlier for eye surgery had resulted in pulmonary aspiration of gastric contents during induction of anesthesia. No further details were available. Preoperatively, he was apprehensive about recurrent aspiration. On the day of surgery, he was given metoclopramide 10 mg and ranitidine 20 mg intravenously; he had taken nothing by mouth for 15 h previously. In the operating room, he was positioned supine with extension of the neck. The cricoid cartilage was identified while the patient was awake. Following adequate preoxygenation, continuous cricoid pressure was applied immediately before the induction of anesthesia with propofol 200 mg and succinylcholine 120 mg in a rapid sequence manner. Laryngoscopy and tracheal intubation with a 7.5 endotracheal tube were easily accomplished, the endotracheal tube cuff was inflated with 10 ml of air, and cricoid pressure was released. This was followed immediately by the appearance of copious, greenish fluid in the mouth, which was suctioned. There were no further sequelae.

Although no prospective randomized controlled clinical studies can be done to prove its clinical efficacy, the above case illustrates that proper application of cricoid pressure is effective, at least in some patients, in the prevention of gastric aspiration from passive regurgitation.

Gundappa Neelakanta, M.D.

References
1. Wraight WJ, Chamney AR, Howells TH: The determination of an effective cricoid pressure. Anaesthesia 1983; 38: 461–6 Bibliographic Links Library Holdings [Context Link]

2. Vanner RG, O'Dwyer JP, Pryle BJ, Reynolds F: Upper oesophageal sphincter pressure and the effect of cricoid pressure. Anaesthesia 1992; 47: 95–100 Bibliographic Links Library Holdings [Context Link]

3. Salem MR, Wong AY, Fizzoti GF: Efficacy of cricoid pressure in preventing aspiration of gastric contents in paediatric patients. Br J Anaesth 1972; 44: 401–4 Bibliographic Links Library Holdings [Context Link]

4. Salem MR, Joseph NJ, Heyman HJ, Belani B, Paulissian R, Ferrara TP: Cricoid compression is effective in obliterating the esophageal lumen in the presence of a nasogastric tube. A nesthesiology 1985; 63: 443–6 [Context Link]

5. Vanner RG, Pryle BJ: Regurgitation and oesophageal rupture with cricoid pressure: A cadaver study. Anaesthesia 1992; 47: 732–5 Bibliographic Links Library Holdings [Context Link]

6. Brimacombe JR, Berry AM: Cricoid pressure. Can J Anaesth 1997; 44: 414–25 Bibliographic Links Library Holdings [Context Link]

 

[VentdependenT]

Venty,

As Mil initially pointed out, and I seconded, we give WAY too many medicines unneedingly.

There is no literature (thanks Sensai) supporting prophylactic B2s in an asymptomatic asthmatic.

Concerning GERD, know what concerns me? Postural GERD. The dude thats taking PPIs and still gets the burning sensation when laying flat.

Those dudes wont get an LMA (say, for a knee scope). But I've identified only a few of them in ten years of practice.

GERD, in my book, well controlled, will get an LMA every time (when an LMA is appropriate). Its laughable that clinicians feel the need to do a rapid sequence induction, complete with the totally useless Selleck maneuver, on these patients.

And for you purists out there, please point me to evidence that shows the Selleck maneuver has any benefit.

If a dude takes a PPI for GERD, and is completely asymptomatic, there is no reason to give them Pepcid/reglan. And there is no need to avoid an LMA.

Challenged by an attending on this issue?

Ask them for data showing that asymptomatic GERD patients have an increased morbidity/mortality from aspiration by 1)not giving pepcid/reglan 2) using an LMA.

After your discussion with your attending, you will 1)stop giving so much pepcid/reglan 2)start using more LMAs.

And with all due respect to your intellectual-Venty-a ss, prophylactic Atrovent doesnt do anything either. Except take up more time, and potentially delay the case because the respiratory terrorist is busy somewhere else.

See evidence of bronchoconstriction pre-op? By all means be aggressive. See if you can ameliorate the symptoms to a point where you feel comfortable going forward.

Been aggressive pre-op and pt still has symptoms? Cancel the case. Very, very, very rare. But it happens.

Asymptomatic COPDer?

No need to give additional medicines.

Funny, how new anesthesiologists conjure what medicines they can give.

And how experienced anesthesiologists figure out how to do a case with as few medicines as possible.

you rock my world baby

I'll have a couple a filthy martinis for you n' yers tonight

 

[VolatileAgent]

OB GYN docs day surgery admit orders at the bottom said "Ventolin Tx On Admit".

this is what you shoulda written in the chart...

"pt given albuterol treatment as instructed by per primary service despite patient being asymptomatic. following rx, severe tachycardia noted with ST segment depressions in lead II, III, and AVF. enzymes drawn and ACS protocol instituted. patient hemodynamically unstable during case secondary to primary service order. started on labetalol drip intraoperatively. patient kept intubated longer than expected with prolonged emergence phase. copy of anesthetic record given to patient."

i guarantee you won't see that order again. of course, that'd probably also destroy your working relationship with this dude. but, sometimes folks gotta be reminded - well-meaning and good intentions, or not - about who's in charge of what.

 

[Noyac]

Absolutely no reason to give a medication that is otherwise not needed just because you're going to put someone to sleep.


I agree with J completely.

I constantly see inexperienced anesthesiologists who constantly give unnecessary medications preop to "minimize" complications/lawsuits.....they make me laugh....except when I have to work with them....

The top meds given unnecessarily in no particular order:

albuterol
reglan
pepcid
bicitra
versed

Top tests ordered unnecessarily ..now that I'm on a roll..again in no particular order:

chem 7
cxr
ecg
pt/ptt
cbc
platelet function study

Mil, can you point me in the direction of some studies showing the lack of support/benefit to reglan and pepcid. I have looked but found nothing very useful. i ask b/c some of our surgeons regularly give these b/4 surgery.

Also, while I am on the subject. I have an orthopod that is giving 10 mg of oxycodone to his pts in the morning of their ambulatory surgery (along with pepcid, and celebrex). He states it is for post-op pain and he learned of it at some conference. What the F*CK.

 

[militarymd]

Mil, can you point me in the direction of some studies showing the lack of support/benefit to reglan and pepcid. I have looked but found nothing very useful. i ask b/c some of our surgeons regularly give these b/4 surgery.

Also, while I am on the subject. I have an orthopod that is giving 10 mg of oxycodone to his pts in the morning of their ambulatory surgery (along with pepcid, and celebrex). He states it is for post-op pain and he learned of it at some conference. What the F*CK.

If you look on the ASA NPO guidelines....you will find all the evidence that is out there.

 

[mustangsally65]

Here's a perspective from a patient with asthma (usually well-controlled, haven't used albuterol in several years). I hate the way it makes me feel. My heart beats right out of my chest, and I get shaky all over. I'd rather be SOB than have to use that thing.

When I had surgery four years ago, I wasn't given albuterol even though I had only been dxed with asthma the previous year. I'm very thankful that I wasn't given any, because that would have been one more thing to have to recover from.

I love visiting this forum, even though I'm still pre-med. You guys talk about the most interesting things. Keep up the good work!