Any of you try propofol as a...

[Lecithin5]

...last resort for PONV? I’ve heard that 1 or 2ccs works wonders, although I’ve never tried it myself.

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[deleted547339]

...last resort for PONV? I’ve heard that 1 or 2ccs works wonders, although I’ve never tried it myself.

I’ve also heard that it’s a great migraine med at super low doses. The problem is that the hospital P&T committee would flip for using a general anesthetic for a migraine, even though it’s insanely low doses.

 

[San Marzano]

I gave 2cc in PACU once with a motivated PACU nurse taking care of the patient. The patient dozed off briefly, then woke up feeling a little better. Who knows.

 

[anbuitachi]

Anyone try adding propofol to coffee?

 

[deleted547339]

Anyone try adding propofol to coffee?

Why would you drink coffee anything but black??

Now a Moscow mule....

 

[dhb]

Anyone try adding propofol to coffee?

Propofol has a horrible taste.

 

[narcotics999]

Anyone try adding propofol to coffee?

I heard it is 80-90% first pass. You can use it as an alternative to cream, I guess.

 

[narcotics999]

I’ve also heard that it’s a great migraine med at super low doses. The problem is that the hospital P&T committee would flip for using a general anesthetic for a migraine, even though it’s insanely low doses.

Time to open a propofol clinic?

 

[DrAmir0078]

No premed for anti PONV?
So, I heard prior to the end of the operation, you can switch to Propofol and off volatiles, this will help smooth waking up and also PONV prevention.

Propofol here, we call it The milk of braves or lions, cause it resembles a local liquor called Arak - it comes clear, but once adding water, it becomes milky color like Propofol

 

[facted]

I've done the propofol as a rescue in pacu a few times. 1-2 mls. Really does work well, actually.

 

[deleted162650]

I know it’s one of @Noyac ’s favorite tricks.

 

[IMGASMD]

Works well.

 

[Hork Bajir]

For those who have had success, how much did you use? I’ve tried 10-20mg on a few occasions without much luck

 

[CopaceticOne]

Yep, I've used it a few times. Give 1cc, wait a bit. Given another cc, wait a bit. (Rinse & repeat, etc)

I distinctly remember one young female where in spite of the PONV ppx, she was still gagging on the way to PACU. After the propofol, she was comfortable when we arrived.

 

[deleted59964]

my n=1
propofol worked great for rescue from PONV in PACU ... for about 40 seconds

 

[nimbus]

my n=1
propofol worked great for rescue from PONV in PACU ... for about 40 seconds

If you give 50mg, they will not complain of nausea for at least 5min.

 

[Guy Caballero]

I know it’s one of @Noyac ’s favorite tricks.

Watch out. His other favorite trick is "hide the salami."

 

[GravelRider]

I’ve had mediocre success with propofol as a PONV rescue. Haldol (0.5mg) works more reliably for ponv, in my experience.

 

[pgg]

Haldol is underutilized. As good or better than droperidol. I miss having that drug.

I routinely use it in young catecholamine charged strong males who you just know are going to wake up angry. 0.5 mg IV about 15 min before wakeup chills them out, same as droperidol.

25 mg of promethazine + 25 mg of ephedrine IM is also good for PONV in the PACU.

 

[deleted59964]

Do you have cyclizine in the U.S?

 

[narcusprince]

Haldol is underutilized. As good or better than droperidol. I miss having that drug.

I routinely use it in young catecholamine charged strong males who you just know are going to wake up angry. 0.5 mg IV about 15 min before wakeup chills them out, same as droperidol.

25 mg of promethazine + 25 mg of ephedrine IM is also good for PONV in the PACU.

The BULLET! I thought their was one more drug in that cocktail. The more end tidal agent you wake your patients up with the more PONV. Zofran is one of the most overrated medications ever. People give it never knowing how effective or not effective it is. Sometimes I am convinced seratonin receptors dont exist in the area postrema....

 

[vector2]

Do you have cyclizine in the U.S?

We have meclizine here but I rarely use it. If someone has failed intra/post-op decadron, zofran, and phenergan, I administer haldol 1mg IV for rescue and then put on a scopolamine patch so they don't get nauseous 4hrs later when they're receiving opioids on the floor.

 

[deleted875186]

The BULLET! I thought their was one more drug in that cocktail. The more end tidal agent you wake your patients up with the more PONV. Zofran is one of the most overrated medications ever. People give it never knowing how effective or not effective it is. Sometimes I convinced seratonin receptors dont exist in the area postrema....

I disagree ... I find Zofran pretty reliable.

One not mentioned is benzos, I find Ativan to be pretty effective.

 

[deleted162650]

Watch out. His other favorite trick is "hide the salami."

Why do you think he gives the propofol.

 

[GlowInTheDark]

Assuming Zofran was already given in OR I go straight to 0.5-1 mg Haldol for PONV. After that, I’ll toss on 12.5 mg of Benadryl. 60% of the time it works every time.

I’ve wanted to try Propofol, but the effort it takes to get it from pharmacy and give it to patient is significantly larger than putting the above orders in and getting the nurse to give it.

 

[deleted547339]

Why do you think he gives the propofol.

Be careful. Anesthesia doesn’t need a David Newman.

 

[AdmiralChz]

Watch out. His other favorite trick is "hide the salami."

Interestingly, patients stop complaining of PONV after that as well.

 

[PainDrain]

The BULLET! I thought their was one more drug in that cocktail. .

Many different variations of the magic IM cocktail. Two I have used are these. 25 mg Promethazine, 25mg ephedrine, 12.5-25mg Benadryl. Or ephedrine, Benadryl, 0.2mg glycopyrolate.

 

[cowbydoc]

I give whatever dose I think will make the patient drift off to sleep for about a minute. It’s usually 2-4cc and has worked great. But I also stay by the bedside until they wake up. I can’t imagine the ramifications on me if something happened after I gave propofol and walked away.

 

[Robotic Wis-Hipple]

I think the propofol sandwhich works, and I’ve used propofol in PACU a handful of times in patients that just weren’t responding to other PONV rescue drugs with decent success but the problem is I have to push it and that’s prohibitive at times.

But I do a lot of TIVAs with multimodal analgesia these days (outside of my hearts) and my PONV pacu calls are minuscule vs before that.

 

[Robotic Wis-Hipple]

Be careful. Anesthesia doesn’t need a David Newman.

This dude; “hold my beer”

https://www.google.com/amp/s/www.da...Canadian-doctor-sentenced-sexual-assault.html

 

[IMGASMD]

This dude; “hold my beer”

https://www.google.com/amp/s/www.da...Canadian-doctor-sentenced-sexual-assault.html

What a piece of s*it

 

[deleted547339]

This dude; “hold my beer”

https://www.google.com/amp/s/www.da...Canadian-doctor-sentenced-sexual-assault.html

Whoa.

 

[BLADEMDA]

Chewing gum for the treatment of postoperative nausea and vomiting: a pilot randomized controlled trial

https://www.sciencedirect.com/science/article/pii/S0007091217301186

 

[zizzer]

I haven't done it enough, but maybe I should start giving 10-20mg of PACU propofol a try since many of you seem to say it works well. I always wonder about whether propofol helps with PONV if you've already given ondansetron though. I thought I remember hearing that propofol also works on via serotonin antagonism, so it seems like it wouldn't help much if ondansetron was already given.

 

[deleted59964]

We have meclizine here but I rarely use it. If someone has failed intra/post-op decadron, zofran, and phenergan, I administer haldol 1mg IV for rescue and then put on a scopolamine patch so they don't get nauseous 4hrs later when they're receiving opioids on the floor.

i give dexamethasone at induction, then droperidol preemergence usually.
Still nauseated in pacu, they get ondansetron and failing that they get cyclizine...

5th line agent I’ve reached only a couple of times ... tried propofol as above

 

[Aether2000]

An interesting analysis of the safety of droperidol. I’m skeptical about … the FDA (part 2) |

 

[propadope]

I’ve also heard that it’s a great migraine med at super low doses. The problem is that the hospital P&T committee would flip for using a general anesthetic for a migraine, even though it’s insanely low doses.

Ive used it for a migraine. Precedex works well too

 

[propadope]

I disagree ... I find Zofran pretty reliable.

One not mentioned is benzos, I find Ativan to be pretty effective.

I’ve used midazolam. Worked well

 

[DM27]

An interesting analysis of the safety of droperidol. I’m skeptical about … the FDA (part 2) |

One of the attendings I worked with as a resident had industry ties and one of his favorite topics was how the Droperidol blackbox was a hatchet job by GSK.

 

[Mman]

Droperidol is a great drug for PONV. Our hospital refuses to carry it at this point and has for several years. I am unaware of anyone that has ever seen a cardiac issue in doses we use in anesthesia. Worst you ever see is the creepy crawly sensation. It's also useful for awake intubations or MAC cases.

 

[bz1024]

Based on my N=1 experience: YES, very effective after patient already received decadron, zofran, and phenergran. When my attending told me to give propofol as the patient was puking his gut out, I was like "I have never heard of that...." but it worked magic. I don't know if it works mainly because it just knocks the patient out or there was actually an underlying MOA like blocking the serotonin receptor pathway....

 

[deleted162650]

It’s hard to feel nauseas when you’re unconscious.

 

[Iso4ane]

IM ephedrine

 

[mdan]

Ann Emerg Med. 2018 Aug;72(2):184-193. doi: 10.1016/j.annemergmed.2018.01.016. Epub 2018 Feb 17.
Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial.
April MD1, Oliver JJ2, Davis WT2, Ong D2, Simon EM2, Ng PC2, Hunter CJ2.

The aromatherapy is sniffing isopropyl alcohol swabs. There is also a Cochrane review and another RCT from 2013 or so showing it is effective. May not be totally applicable to recovery room but worth a try if all else fails as there is little risk/harm and easy to try.

 

[PainDrain]

Ann Emerg Med. 2018 Aug;72(2):184-193. doi: 10.1016/j.annemergmed.2018.01.016. Epub 2018 Feb 17.
Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial.
April MD1, Oliver JJ2, Davis WT2, Ong D2, Simon EM2, Ng PC2, Hunter CJ2.

The aromatherapy is sniffing isopropyl alcohol swabs. There is also a Cochrane review and another RCT from 2013 or so showing it is effective. May not be totally applicable to recovery room but worth a try if all else fails as there is little risk/harm and easy to try.

This was an old trick I learned from our PACU nurses. Place an alcohol pad next to the patient’s nose and it will help with their nausea; not convinced it’s that effective.


Also, a D5 LR bolus of 500-1L works pretty well as a rescue. I use this if all else fails and there is some research showing its effective.

 

[Laryngophed]

i give dexamethasone at induction, then droperidol preemergence usually.
Still nauseated in pacu, they get ondansetron and failing that they get cyclizine...

5th line agent I’ve reached only a couple of times ... tried propofol as above

It's been since June that I performed an anesthetic, however my usual practice was dexamethasone shortly after induction (it's poor form to give it awake in the typical anesthesia fashion), and then ondansetron just prior to wakeup. I also did everything I could to minimize opioids, so I used lots of ketamine and dexmedetomidine intraop and peri-emergence. Scop patch on meeting in the pre-op area if they had a history of PONV. I used aprepitant a few times and it seemed to work well, but that was on people whose PONV was so profound they were getting a TIVA and no volatile.

In the PACU, I routinely provided promethazine, but I might add 0.5-1mg of haloperidol and/or midazolam for PONV. I used 10-30mg of propofol a few times in the PACU and it seemed to be enough to interrupt a cycle of emesis and let the other stuff catch up.

 

[Laryngophed]

One of the attendings I worked with as a resident had industry ties and one of his favorite topics was how the Droperidol blackbox was a hatchet job by GSK.

"Don't use droperidol, it prolongs the QTc. Here, try this ondansetron."

 

[nimbus]

This was an old trick I learned from our PACU nurses. Place an alcohol pad next to the patient’s nose and it will help with their nausea; not convinced it’s that effective.


Also, a D5 LR bolus of 500-1L works pretty well as a rescue. I use this if all else fails and there is some research showing its effective.

Reminds me of this.

Emetrol® Nausea Medication

 

[deleted59964]

It's been since June that I performed an anesthetic, however my usual practice was dexamethasone shortly after induction (it's poor form to give it awake in the typical anesthesia fashion), and then ondansetron just prior to wakeup. I also did everything I could to minimize opioids, so I used lots of ketamine and dexmedetomidine intraop and peri-emergence. Scop patch on meeting in the pre-op area if they had a history of PONV. I used aprepitant a few times and it seemed to work well, but that was on people whose PONV was so profound they were getting a TIVA and no volatile.

In the PACU, I routinely provided promethazine, but I might add 0.5-1mg of haloperidol and/or midazolam for PONV. I used 10-30mg of propofol a few times in the PACU and it seemed to be enough to interrupt a cycle of emesis and let the other stuff catch up.

Ketamine is quite emetogenic ...