Another Very Important Jet Clinical Thread

[jetproppilot]

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.

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[rmh149]

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).

 

[Noyac]

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).

Why 8mg zofran?

 

[rmh149]

Why 8mg zofran?

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.

 

[Planktonmd]

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.

Give some Dexamethasone with it and you won't need to increase the dose.

 

[Noyac]

Give some Dexamethasone with it and you won't need to increase the dose.

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.

 

[jwk]

Give some Dexamethasone with it and you won't need to increase the dose.

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.

 

[rmh149]

Give some Dexamethasone with it and you won't need to increase the dose.

Good idea. I'm going to try that.

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

 

[Planktonmd]

Good idea. I'm going to try that.

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

No,

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

 

[rmh149]

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.

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.

 

[VolatileAgent]

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.

 

[Noyac]

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.

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.

 

[BLADEMDA]

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.

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

 

[rmh149]

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.

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.

 

[BLADEMDA]

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.

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.

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.

 

[Noyac]

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.

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.

 

[VentdependenT]

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.

 

[jetproppilot]

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

HAHAHAHAHAHHAHAHHA

That made me laugh, venty.

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