1. Download free Tapatalk for iPhone or Tapatalk for Android for your phone and follow the SDN forums with push notifications.
    Dismiss Notice

Another Very Important Jet Clinical Thread

Discussion in 'Anesthesiology' started by jetproppilot, May 2, 2007.

  1. jetproppilot

    jetproppilot Turboprop Driver
    10+ Year Member

    Joined:
    Mar 12, 2005
    Messages:
    5,861
    Likes Received:
    102
    Moral of this post is:

    YOU DON'T HAVE TO INTUBATE D&Cs BECAUSE OF WHAT YOU'VE BEEN TAUGHT ABOUT "ASPIRATION RISK".

    OK.

    I know what the academic dudes say.

    D&C.

    Twelve week-or-greater uterus, you need a tube.

    Physiologic/hormonal changes effecting gastric emptying, blah blah blah.

    Most run-of-da'-mil private practice hospitals have GYN dudes that are skilled and you're talkin' about a 228 second procedure.

    INTUBATING THIS LADY IS OVERKILL AND YOUR ANESTHETIC WILL NOW BECOME A HURDLE GREATER THAN THE SURGERY.

    Because now you (and the lady) has to worry about sore throat from intubation, prolonged wake-up because she was paralyzed, N/v from reversal, etc.

    All because we were taught a twelve-week uterus means increased risk of aspiration. Which is WAY overplayed.

    Even though, in the United Kingdom, GA continues to be a well accepted anesthetic for C sections, with morbidity/mortality numbers no-worse than ours.

    So I'm calling BULLS HIT on the twelve week-ya-gotta-intubate-her rule.

    I think allopathic-anesthesia education on the risks of early-parturient aspiration are WAY overplayed. And my experience, and the experience of every clinician I know backs up that notion.

    Its very rare that I tube a D&C.

    midazolam 2 mg/ketorolac 30 mg on the way to the OR.

    Bring her in, hooker up.

    150 mg propofol.

    N20 70%, O2 30 %.

    She'll start to breathe eventually.

    If the GYN dude is deft, no agent required.

    If he's struggling a little, crank the sevo/des commensurate to his struggle.

    D&C over?

    DC the yellow/blue gas on your-still-spontaneously-ventilating lady.

    You wanna tube every 12-week-and-greater-uterus-D&C?

    I respect your decision.

    I'm telling you that in eleven years of private practice I've tubed less than ten D&Cs.

    I'm either really lucky, or the teaching is too strong concerning aspiration risk.

    MOST D&Cs CAN BE DONE BY MASK/LMA GA. Unless you're working with an cdazy-slow private-practice GYN or academic institution-where-you're-growing-a-beard-waiting for the case to end.
     
  2. Note: SDN Members do not see this ad.

  3. rmh149

    2+ Year Member

    Joined:
    Apr 9, 2007
    Messages:
    396
    Likes Received:
    0
    Status:
    Non-Student
    Same here. Although, I will intubate a D&C if they are morbidly obese.

    Unfortunately the OR staff is sooooo slow to prep the patient, my propofol isnt enough for them to not move. I usually will use a little agent. 100% O2.
    I found that using more propofol slowed the wake up and recovery time compared to induction propofol and agent.

    I also skip the versed unless they are overly anxious. Instead, I give them a 30-50mg of propofol right before going into the room. Flip side - It does look odd to have a gigantic 30cc syringe in your shirt pocket in pre-op.

    fentanyl 50mcg, Toradol 30mg, zofran 8mg (now that its cheap).
     
  4. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,512
    Likes Received:
    2,065
    Status:
    Attending Physician

    Why 8mg zofran?
     
  5. rmh149

    2+ Year Member

    Joined:
    Apr 9, 2007
    Messages:
    396
    Likes Received:
    0
    Status:
    Non-Student
    I have found that 4mg of zofran works well...but not 100%. I still get calls from the recovery nurse or same day surgery nurse with complaints of PONV. Maybe 20%....just a guess.

    When Zofran went generic, the cost is around $1.5. I bumped my dose to 8mg IV pre-anesthetic bringing it closer to the recomended 150mcg/kg IV q4h dose for chemotherapy patients. This is around 10mg IV for a 70kg patient.

    Since I have been giving 8mg prior to anesthesia I rarely get calls with complaints of PONV. Thus decreasing our PONV complication and delayed discharge rate.

    I have also read that 16mg IV prior to anesthesia is recommended for PONV prevention....but I just can imagine drawing up 4 little 2cc vials. 8mg works just fine. And the pharmacy no longer complains about zofran use now that it is cheap.
     
  6. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 2, 2006
    Messages:
    6,809
    Likes Received:
    1,773
    Status:
    Attending Physician
    Give some Dexamethasone with it and you won't need to increase the dose.
     
  7. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,512
    Likes Received:
    2,065
    Status:
    Attending Physician
    Absolutely. And even though it costs less now that it is generic, what is the cost to the pt and the system? It ain't $1.50 I can tell you that. I'm sure you know the literature about zofran and all the others as well but 8 mg is not routinely supported to be superior to the standard 4 mg dose. Plus, giving it pre-op is also not recommended routinely. You have to be careful when you read something and take the circumstances into account. The literature is more supportive of 5-HT receptor antagonists being given 15 - 30 min b/4 the end of the case. Anzemet I give earlier (30 min b/4 the end) b/c it is a prodrug as opposed to zofran so it takes longer to work.
    So my point is, the cost may not be that much to the hospital but it is still substantial to the system. Did you know what your pharmacy bills the pt for 1 dose of generic zofran? It is't $1.50. Why not give somehting that is even more effective (ie: decadron and zofran) instead of 2 doses of zofran? Just my .02. You can practice however you see fit.
     
  8. jwk

    jwk CAA, ASA-PAC Contributor
    10+ Year Member

    Joined:
    Apr 30, 2004
    Messages:
    3,490
    Likes Received:
    560
    Still that pesky AVN to worry about. I had just about quit worrying about it and a very well-respected academic anesthesiologist I heard a couple of weeks ago did to - until the 16 y/o daughter of a friend of his got bilateral AVN from a couple of doses of decadron for PONV prophylaxis.
     
  9. rmh149

    2+ Year Member

    Joined:
    Apr 9, 2007
    Messages:
    396
    Likes Received:
    0
    Status:
    Non-Student
    Good idea. I'm going to try that.

    Do you ever see patients complaining about side effects from decadron, mainly bloating and gastritis?
     
  10. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 2, 2006
    Messages:
    6,809
    Likes Received:
    1,773
    Status:
    Attending Physician
    No,

    Just don't inject it fast in an awake female patient, they will not appreciate the the perineal burning sensation.
     
  11. rmh149

    2+ Year Member

    Joined:
    Apr 9, 2007
    Messages:
    396
    Likes Received:
    0
    Status:
    Non-Student
    Noyac, that totally makes sense. I am going to call the director of the pharmacy tomorrow to see what the cost to the patient is. Thanks, I didn’t think of that. Even though we are in a private hospital and the bottom line/profit is important to the hospital....I don’t wish to dive up that cost when there is a better way of practicing.
     
  12. VolatileAgent

    VolatileAgent Livin' the dream
    7+ Year Member

    Joined:
    Jul 6, 2005
    Messages:
    1,037
    Likes Received:
    1
    you can give 4mg prophylactically and use the othe 4mg as a rescue. or, in the high risk patient you can prescribe emend prophylactically before the procedure. problem is that it's $35 per dose.
     
  13. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,512
    Likes Received:
    2,065
    Status:
    Attending Physician
    We sent the emend rep away (after lunch) till the cost is more reasonable. If we had a problem with PONV then maybe we would have been interested. It is a rare case that has any significant PONV at my facility.
     
  14. BLADEMDA

    BLADEMDA ASA Member
    10+ Year Member

    Joined:
    Apr 22, 2007
    Messages:
    16,713
    Likes Received:
    2,900
    Status:
    Attending Physician

    Recent study in one of our Journals showed 4mg Decadron plus 4mg Zofran a nice combo. The study commented that 2mg Zofran was sufficient but since my hospital pays $1.00 for the generic 4mg vial I use the complete amount.
    Thus, 4mg of Decadron combined with 4mg generic Zofran at the end of the case. I also add 0.625mg of droperidol intraop (for the right patient). If N/V still occurs in Pacu give second 4mg dose of Zofran (efficacy increases only slightly with additional 4mg). Finally, another good study showed low dose phenergan 6.25mg is very effective as rescue anti-emetic in Pacu with minimal sedative properties.

    All my comments are EVIDENCE based medicine and I have the studies to back them up. The total cost for everything listed above plus Reglan in holding area is $5.00. Reglan 10mg dose is not very effective as anti-emetic. Studies show you need at least 20mg-30mg dose for anti-nausea effect (I currently don't use high dose Reglan).

    I use EMEND sparingly only on SDS Cases with a history of severe Nausea and vomiting with anesthesia. In addition, the patient needs to be undergoing Laparascopic surgery or Breast Surgery. Again, May's Journal has a good study by TJ Gan showing minimal superiority over Zofran; that said, I give the "full metal jacket" to those SDS Cases described above.

    It never hurts to apply a little evidence based medicine in your practice. I find that this works well most of the time.

    Blade
     
  15. rmh149

    2+ Year Member

    Joined:
    Apr 9, 2007
    Messages:
    396
    Likes Received:
    0
    Status:
    Non-Student
    We currently use emend for our gastric bypass patients. Actually, the surgeon has the patient take it before coming to the hospital. $50/pill.....ouch. I dont do the anesthesia for those cases but I will ask the anesthesiologists to see if they see a difference. The rep has been so far up the surgeons ***, the director of pharmacy had to get security to escort her out of the hospital.:laugh:

    I am going to adjust my fight against PONV, with Zofran 4mg and decadron for mostly everyone. Add Reglan 10mg and 6.25mg phenergan for the high risk.
     
  16. BLADEMDA

    BLADEMDA ASA Member
    10+ Year Member

    Joined:
    Apr 22, 2007
    Messages:
    16,713
    Likes Received:
    2,900
    Status:
    Attending Physician

    Remember, the following:

    1. Decadron- 4mg is enough when you combine it with other anti-emetics.
    must be given in holding area (after the Versed please ) or
    at Induction

    2. Emend- Very expensive and should be reserved for OUTPATIENT
    surgery only and the highest risk cases. Be very Selective.

    3. Reglan- 10mg dose good for reducing gastric volume in 1-5 minutes
    but "weak" anti-emetic. Some use high dose Reglan I don't
    because of side-effect profile.

    4. Phenergan- Great rescue anti-emetic in Pacu. Only need to start with
    6.25 mg dose. You can give a second dose if
    needed

    5. Zofran Hospital cost around $1.00. Give 4mg at the end of the
    case. It is very cheap now so if you want to give another
    4mg go ahead (some benefit but minimal). I give second 4mg
    dose in Pacu if needed.

    6. Droperidol- I avoid this drug in the holding area. A few female patients
    have told me of "panic attacks/anxiety" with the drug.
    I no longer use it routinely but do give 0.625mg
    intraoperatively to "at risk" patients. My Group has used this
    dose on more than 100,000 cases with no known problems
    when given INTRAOPERATIVELY at the low dose.
     
  17. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,512
    Likes Received:
    2,065
    Status:
    Attending Physician

    Well noted here. The one thing I was going to mention from an earlier post was that decadron needs to be given early (right after induction) b/c it needs time to work.
     
  18. VentdependenT

    VentdependenT You didnt build thaT
    Physician Moderator Emeritus 10+ Year Member

    Joined:
    Oct 3, 2003
    Messages:
    4,010
    Likes Received:
    19
    Status:
    Fellow [Any Field]
    scopolomine patch an hour before in the holding area works well too. I'd avoid it in the old folks or demetia prone peeps but otherwise its a good combo with yer other anti-emitics. and its dirt cheap.

    good to have you back with yer C#$K swanging jet.
     
  19. jetproppilot

    jetproppilot Turboprop Driver
    10+ Year Member

    Joined:
    Mar 12, 2005
    Messages:
    5,861
    Likes Received:
    102
    HAHAHAHAHAHHAHAHHA

    That made me laugh, venty.

    I agree about the scop patch. I like 'em too.
     

Share This Page