Dilaudid

[doctor712]

Well, lemme just say this was a personal experience this weekend.
Went to ER near house for an intractable pain not relived by lidocaine. Which has never failed me.
Assumed viral throat issue that would resolve. Pushed fluids.
Left with Vicodin first time. (never took something like this In my 39
Years). Left with a wave and a lollipop 2nd time, 24 hours later.
Felt like attacking the miserable CCFL ER doc who clearly thought I needed
A psych consult. Especially since I was the only patient in the ER. 12 more hours later, I decided to goto the Big shop further away.
Got to ER and was admitted. (oh well what do u know DIC& face lazy doc near my house -
I'm not FINE!!!!!).

In ER 5pm CT Scan with contrast and With notable findings.
A little worried but my wonderful friend and PGY4 say bedside to keep me company
After a long shift. Angel.

7pm Toradol. No relief.

12am ENT scope (must've made that guy happy, though
he was exceptionally thorough. More so than prior scopes.)
Notable findings. As in, "I've never seen that before. My
Chief either.".

2am morphine 2mg. no relief. Pain 10:10 for 5 days now. 24/7.
Never felt that feeling of such a rush. Not terribly enjoyable at first especially. Felt
Like big John stud was sitting on my chest pouring hot water over me. Locally,
No relief. Zilch.

4am I call nurse and attending over and tell them that I've had 0 relief from morphine.

415am: decadron. Meh.
416am: DILAUDID. Asked later, 1mg. which i was later
Told is many times more potent than morphine. This was after
Telling them I didn't dig the morphine "rush.". As the nurse is squirting
She's listing the feelings I MAY (as In will) have.
416:10 seconds. Nurse walks away. Now Andre the giant is taking big John
Stud and body slamming him over every centimeter of my body. Jimmy snuka
Is doing his superfly thing on my face. And oh my ass itches
Intensely for 5 seconds. The subsiding. Same with chest. For some
Reason this clues the nurse to check my BP. HA.
4:18 I'm pain free for first time in 5 days of 10:10 pain day and night, to point of weeping at one moment. (u guessed it, at home after CCFL ER doc have me a pat and sent me home ).
Last 48 hours on floor. Visited by all my friends and bosses. Getting amazing pain relief and
Teams of specialists getting to bottom of underlying causes.

This was just a note to u all as I am feeling thankful during my first hospital visit as
An adult for not feeling like a number, for getting amazing care, and for all
You guys and gals doing what u do day In and day out for your patients. I've had consults from multiple teams, some of which the docs put their notes Down and just talked to me for an hour. Or 30 mins.

And no, this isn't the morphine talking.

Thank u for your dedication to healing,
D712

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[Somnus Tuto]

.

 

[DrBeaker]

IV dexamethasone to an awake patient, ouch.

 

[doctor712]

Ouch burn? I can't recall. Too close to dilaudid but sounds familiar. Morphine stings when it goes in. That I recall.
Tonight, we've switched over to liquid roxicet. No idea why, but has given me
Incredible and complete pain relief. 0:10. Even morphine and dilaudid didn't do that.
Never woulda thought it would be better, for that acute pain, than the big boys.
But it's great!!!!!
D712

 

[DrBeaker]

Ouch burn? I can't recall. Too close to dilaudid but sounds familiar. Morphine stings when it goes in. That I recall.
Tonight, we've switched over to liquid roxicet. No idea why, but has given me
Incredible and complete pain relief. 0:10. Even morphine and dilaudid didn't do that.
Never woulda thought it would be better, for that acute pain, than the big boys.
But it's great!!!!!
D712

Yeah ouch burn. IV decadron (dexamethasone) will cause your patient to feel very uncomfortable due to intense perineal burning. I've only heard of this, have not seen it for myself. Been meaning to try it on someone...

 

[pgg]

Yeah ouch burn. IV decadron (dexamethasone) will cause your patient to feel very uncomfortable due to intense perineal burning. I've only heard of this, have not seen it for myself. Been meaning to try it on someone...

Great Balls Of Fire!

 

[FiremedicMike]

Yeah ouch burn. IV decadron (dexamethasone) will cause your patient to feel very uncomfortable due to intense perineal burning. I've only heard of this, have not seen it for myself. Been meaning to try it on someone...

Interesting, I've given IV decadron many times, never had a patient express those feelings.

(Our dose is 10mg if that matters)

 

[cincincyreds]

Interesting, I've given IV decadron many times, never had a patient express those feelings.

(Our dose is 10mg if that matters)

I've seen this a couple of times, basically I give the decadron awake before inducing the patient. Only have seen in females, not males.

 

[jumpingforjoy]

I've seen this a couple of times, basically I give the decadron awake before inducing the patient. Only have seen in females, not males.

Do you see the patient writhing on the table trying to scratch the itch? what a sight.

 

[Mman]

Yeah ouch burn. IV decadron (dexamethasone) will cause your patient to feel very uncomfortable due to intense perineal burning. I've only heard of this, have not seen it for myself. Been meaning to try it on someone...

Happens not infrequently, probably at least 20% of the time would be my guess. Most patients just don't admit to it and you only notice it if they can't hide it. But if you ask, they'll tell you.

 

[doctor712]

Yeah ouch burn. IV decadron (dexamethasone) will cause your patient to feel very uncomfortable due to intense perineal burning. I've only heard of this, have not seen it for myself. Been meaning to try it on someone...

Well, the as$ itching I described may now have an explanation.
she gave the decadron so close to the dilaudid it could have been the decadron.
d712

 

[doctor712]

Interesting, I've given IV decadron many times, never had a patient express those feelings.

(Our dose is 10mg if that matters)

I recall 20mg of decadron. But I also recall rainbows and lollipops.
D712

 

[doctor712]

Also, i got 1 mg of dilaudid. i don't know what u dose awake patients
At, but I cannot fathom more than 2mg, wonder what an IV drug user needs. Lord.
d712

 

[doctor712]

Happens not infrequently, probably at least 20% of the time would be my guess. Most patients just don't admit to it and you only notice it if they can't hide it. But if you ask, they'll tell you.

I guess not too many admit it on SDN too. Ha.

D712

 

[btbam]

Also, i got 1 mg of dilaudid. i don't know what u dose awake patients
At, but I cannot fathom more than 2mg, wonder what an IV drug user needs. Lord.
d712

Generally, I wouldn't give more than 0.5 mg at a time. 2 mg is a pretty hefty dose

 

[pgg]

At, but I cannot fathom more than 2mg, wonder what an IV drug user needs. Lord.

Sky's the limit

Chronic pain patients have been known to burn through entire hospital pharmacy stocks with a couple days' hard PCA use.

 

[BLADEMDA]

Happens not infrequently, probably at least 20% of the time would be my guess. Most patients just don't admit to it and you only notice it if they can't hide it. But if you ask, they'll tell you.

No. IT happens to men and women. Perineal/Vaginal burning in women and Rectal burning in men. It is a dose related side-effect with about a 1% incidence at 4 mg which climbs to 2-4% at 8-10 mg IV. My "N" is way bigger than yours in this area.

My percentages reflect major discomfort/burning/pain and NOT mild irritation. Fortunately, this side-effect is short lived with most reporting pain/discomfort less than 5 min in duration.

 

[BLADEMDA]

Also, i got 1 mg of dilaudid. i don't know what u dose awake patients
At, but I cannot fathom more than 2mg, wonder what an IV drug user needs. Lord.
d712

Ever had a Kidney stone? You will not be impressed at 2 mg IV with a painful kidney stone. Some patients are just getting started at 2 mg IV with an acute stone.

 

[BLADEMDA]

Intravenous Dexamethasone Induced-Perineal Irritation

• Adriana Nizam, Registrar, Noreen Dowd

Dept. of Anaesthesia St. James's Hospital, Dublin, Ireland
Dear Editor
Single dose intravenous administration of dexamethasone reduces the incidence of post-operative nausea and vomiting 1;2. Its effectiveness when administered before the induction of anaesthesia is well described 3-
More... Dear Editor
Single dose intravenous administration of dexamethasone reduces the incidence of post-operative nausea and vomiting 1;2. Its effectiveness when administered before the induction of anaesthesia is well described 3- 4. However there is little in the anaesthetic literature on a unique and unpleasant side effect we recently observed following intravenous dexamethasone (Faulding), in two female patients undergoing day case gynaecological surgery 5-7.
Case 1: A 32-year-old female, undergoing diagnostic laparoscopy, complained of an excruciating, sharp pain and burning sensation in her perineal area approximately 20 s after an intravenous dexamethasone bolus (8mg). The pain was so severe that the patient screamed and sat up abruptly. Fentanyl (100 mcg) and midazolam (2 mg) were given intravenously and the patient was reassured. The pain subsided in less than 30 s. Anaesthesia was induced and the procedure was otherwise uneventful. Post-operatively the patient remained stable, comfortable and pain free. She recalled the incident and was satisfied with the explanation given.
Case 2: A 27-year-old female, undergoing hysteroscopy complained of severe, sharp, burning pain in her perineum approximately 15 s after an intravenous bolus of dexamethasone (8 mg). Anaesthesia was immediately induced. The procedure continued uneventfully. Post-operatively, the patient recalled the pain and was satisfied with the explanation given.
Dexamethasone alone or in combination with other antiemetics is an effective antiemetic 1; 8-9. It is suggested that when administered immediately prior to induction of anaesthesia it provides effective antiemesis throughout the first 24 hours post-operatively 3. Intravenous dexamethasone-induced perineal irritation has been described in association with antiemetic use in chemotherapy, during treatment of acute head injury and when dexamethasone is used as an anti-inflammatory agent in maxillo-facial surgery. This side effect of dexamethasone is described in British National Formulary (BNF)10. However there is a paucity of information in the anaesthetic literature 5-7. Furthermore in systematic reviews and anaesthetic text books observed, there was no reference to this distressing side effect 1-2. In the cases described both patients reported that the pain was very distressing. They both recalled the pain postoperatively but reported that it was short-lived and caused them no further distress.
The cause of this phenomenon is still not fully understood. A phosphate ester which is part of this corticosteroid (dexamethasone sodium phosphate) might play an important role. The short nature of the pain could be due to the short duration needed to hydrolyse the compound to phosphate ions and dexamethasone 11. The lack of reports in the anaesthetic literature may be because patients are never asked regarding this pain or are embarrassed to mention it.
To conclude, we report this observation to increase awareness of this side effect among anaesthetists. Based on the experience of our patients, when dexamethasone is used for prophylaxis of PONV, it should be given after induction of anaesthesia. If administering it prior to induction, it seems reasonable to advise the patient of potential perineal pain before administration. Furthermore, diluting the drug in 50 ml of normal saline and administering it over 2 mins may reduce the incidence of pain 12.
References
(1) Henzi I, Walder B, Tramer MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg 2000; 90(1):186-194.
(2) Habib AS, Gan TJ. Evidence-based management of postoperative nausea and vomiting: a review. Can J Anaesth 2004; 51(4):326-341.
(3) Wang JJ, Ho ST, Tzeng JI, Tang CS. The effect of timing of dexamethasone administration on its efficacy as a prophylactic antiemetic for postoperative nausea and vomiting. Anesth Analg 2000; 91(1):136-139.
(4) Elhakim M, Nafie M, Mahmoud K, Atef A. Dexamethasone 8 mg in combination with ondansetron 4 mg appears to be the optimal dose for the prevention of nausea and vomiting after laparoscopic cholecystectomy. Can J Anaesth 2002; 49(9):922-926.
(5) Neff SP, Stapelberg F, Warmington A. Excruciating perineal pain after intravenous dexamethasone. Anaesth Intensive Care 2002; 30(3):370- 371.
(6) Perron G, Dolbec P, Germain J, Bechard P. Perineal pruritus after i.v. dexamethasone administration. Can J Anaesth 2003; 50(7):749- 750.
(7) Crandell JT. Perineal pruritus after the administration of iv dexamethasone. Can J Anaesth 2004; 51(4):398-399.
(8) Thomas R, Jones N. Prospective randomized, double-blind comparative study of dexamethasone, ondansetron, and ondansetron plus dexamethasone as prophylactic antiemetic therapy in patients undergoing day-case gynaecological surgery. Br J Anaesth 2001; 87(4):588-592.
(9) Wang JJ, Ho ST, Liu HS, Ho CM. Prophylactic antiemetic effect of dexamethasone in women undergoing ambulatory laparoscopic surgery. Br J Anaesth 2000; 84(4):459-462.
(10) British National Formulary. BMJ Publishing Group Ltd, RPS Publishing. Volume 54,September 2007; 380.
(11) Which form of intravenous hydrocortisone? Drug Therapy Bulletin 17, 71-72. 1979.
(12) Czerwinski AW, Czerwinski AB, Whitsett TL, Clark ML Effect of a single large intravenous injection of dexamethasone. Clin Pharmacol Ther 1972; 13: 638-42

 

[doctor712]

Ever had a Kidney stone? You will not be impressed at 2 mg IV with a painful kidney stone. Some patients are just getting started at 2 mg IV with an acute stone.

No. So, I have no frame of reference with kidney stones with the pain I was in. Other than hearing Kidney stones are like child birth. This was the worst pain of my life though, that I can say.

Perhaps I would have had better comfort with more than 2mg, but I just didn't like the overwhelming feeling, so I nixed any more Dilaudid. Though questioned that after the fact.

My itching/discomfort lasted 10 secs. n=me.

D712

 

[doctor712]

No. IT happens to men and women. Perineal/Vaginal burning in women and Rectal burning in men. It is a dose related side-effect with about a 1% incidence at 4 mg which climbs to 2-4% at 8-10 mg IV. My "N" is way bigger than yours in this area.

My percentages reflect major discomfort/burning/pain and NOT mild irritation. Fortunately, this side-effect is short lived with most reporting pain/discomfort less than 5 min in duration.

For the record, the nurse seemed to not know why I was having such sudden perineal discomfort, thus she rushed for the BP cuff (I imagine to see if I were having some poor systemic reaction). It would have been nice to know it was a side effect going in.

D712

 

[BLADEMDA]

For the record, the nurse seemed to not know why I was having such sudden perineal discomfort, thus she rushed for the BP cuff (I imagine to see if I were having some poor systemic reaction). It would have been nice to know it was a side effect going in.

D712

Sorry man. Since it happens "rarely" even at higher doses Nurses may not have seen it before. I limit my Dexamethasone dose in awake patients to 4 mg IV and this side-effect is very rare at that dosage. At 8 mg it is still uncommon but the incidence climbs significantly. ENT likes to give 10-12 mg IV to some of their patients in holding as a "pre-med" so I am familiar with RECTAL BURNING COMPLAINTS or "my ass-hole is on fire."

Simply diluting the higher dosages of Decadron in a 20 ml syringe and pushing it slowly over 60 seconds will decrease the incidence of major complaints to 1%.

 

[doctor712]

Intravenous Dexamethasone Induced-Perineal Irritation

• Adriana Nizam, Registrar, Noreen Dowd

Dept. of Anaesthesia St. James's Hospital, Dublin, Ireland
Dear Editor
Single dose intravenous administration of dexamethasone reduces the incidence of post-operative nausea and vomiting 1;2. Its effectiveness when administered before the induction of anaesthesia is well described 3-
More... Dear Editor
Single dose intravenous administration of dexamethasone reduces the incidence of post-operative nausea and vomiting 1;2. Its effectiveness when administered before the induction of anaesthesia is well described 3- 4. However there is little in the anaesthetic literature on a unique and unpleasant side effect we recently observed following intravenous dexamethasone (Faulding), in two female patients undergoing day case gynaecological surgery 5-7.
Case 1: A 32-year-old female, undergoing diagnostic laparoscopy, complained of an excruciating, sharp pain and burning sensation in her perineal area approximately 20 s after an intravenous dexamethasone bolus (8mg). The pain was so severe that the patient screamed and sat up abruptly. Fentanyl (100 mcg) and midazolam (2 mg) were given intravenously and the patient was reassured. The pain subsided in less than 30 s. Anaesthesia was induced and the procedure was otherwise uneventful. Post-operatively the patient remained stable, comfortable and pain free. She recalled the incident and was satisfied with the explanation given.
Case 2: A 27-year-old female, undergoing hysteroscopy complained of severe, sharp, burning pain in her perineum approximately 15 s after an intravenous bolus of dexamethasone (8 mg). Anaesthesia was immediately induced. The procedure continued uneventfully. Post-operatively, the patient recalled the pain and was satisfied with the explanation given.
Dexamethasone alone or in combination with other antiemetics is an effective antiemetic 1; 8-9. It is suggested that when administered immediately prior to induction of anaesthesia it provides effective antiemesis throughout the first 24 hours post-operatively 3. Intravenous dexamethasone-induced perineal irritation has been described in association with antiemetic use in chemotherapy, during treatment of acute head injury and when dexamethasone is used as an anti-inflammatory agent in maxillo-facial surgery. This side effect of dexamethasone is described in British National Formulary (BNF)10. However there is a paucity of information in the anaesthetic literature 5-7. Furthermore in systematic reviews and anaesthetic text books observed, there was no reference to this distressing side effect 1-2. In the cases described both patients reported that the pain was very distressing. They both recalled the pain postoperatively but reported that it was short-lived and caused them no further distress.
The cause of this phenomenon is still not fully understood. A phosphate ester which is part of this corticosteroid (dexamethasone sodium phosphate) might play an important role. The short nature of the pain could be due to the short duration needed to hydrolyse the compound to phosphate ions and dexamethasone 11. The lack of reports in the anaesthetic literature may be because patients are never asked regarding this pain or are embarrassed to mention it.
To conclude, we report this observation to increase awareness of this side effect among anaesthetists. Based on the experience of our patients, when dexamethasone is used for prophylaxis of PONV, it should be given after induction of anaesthesia. If administering it prior to induction, it seems reasonable to advise the patient of potential perineal pain before administration. Furthermore, diluting the drug in 50 ml of normal saline and administering it over 2 mins may reduce the incidence of pain 12.
References
(1) Henzi I, Walder B, Tramer MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg 2000; 90(1):186-194.
(2) Habib AS, Gan TJ. Evidence-based management of postoperative nausea and vomiting: a review. Can J Anaesth 2004; 51(4):326-341.
(3) Wang JJ, Ho ST, Tzeng JI, Tang CS. The effect of timing of dexamethasone administration on its efficacy as a prophylactic antiemetic for postoperative nausea and vomiting. Anesth Analg 2000; 91(1):136-139.
(4) Elhakim M, Nafie M, Mahmoud K, Atef A. Dexamethasone 8 mg in combination with ondansetron 4 mg appears to be the optimal dose for the prevention of nausea and vomiting after laparoscopic cholecystectomy. Can J Anaesth 2002; 49(9):922-926.
(5) Neff SP, Stapelberg F, Warmington A. Excruciating perineal pain after intravenous dexamethasone. Anaesth Intensive Care 2002; 30(3):370- 371.
(6) Perron G, Dolbec P, Germain J, Bechard P. Perineal pruritus after i.v. dexamethasone administration. Can J Anaesth 2003; 50(7):749- 750.
(7) Crandell JT. Perineal pruritus after the administration of iv dexamethasone. Can J Anaesth 2004; 51(4):398-399.
(8) Thomas R, Jones N. Prospective randomized, double-blind comparative study of dexamethasone, ondansetron, and ondansetron plus dexamethasone as prophylactic antiemetic therapy in patients undergoing day-case gynaecological surgery. Br J Anaesth 2001; 87(4):588-592.
(9) Wang JJ, Ho ST, Liu HS, Ho CM. Prophylactic antiemetic effect of dexamethasone in women undergoing ambulatory laparoscopic surgery. Br J Anaesth 2000; 84(4):459-462.
(10) British National Formulary. BMJ Publishing Group Ltd, RPS Publishing. Volume 54,September 2007; 380.
(11) Which form of intravenous hydrocortisone? Drug Therapy Bulletin 17, 71-72. 1979.
(12) Czerwinski AW, Czerwinski AB, Whitsett TL, Clark ML Effect of a single large intravenous injection of dexamethasone. Clin Pharmacol Ther 1972; 13: 638-42

Good info Blade. Thx.

On another anesthetic note, when ENT was scoping me, prior to, I asked to make sure he used plenty of nasal anesthetic. As, outpatient, it took a bunch to make me comfortable x2 a year ago. He said, "I'm happy you pointed that out, because here in the ER, when we scope, we don't use local anesthesia. But since I have it with me, I'll use some on you." I was a camper, that much I can say. He scoped below my chords, where my issue turned out to be. Isn't that essentially an awake intubation? Flex scope vs. ETT, sure, but I was 100% comfy with the nasal anesthesia. Was down there for 2-3 minutes total. :thumb up:

Overall, I got AMAZING care from ER to Hospital discharge. And could not have been happier with every person I encountered. Unlike, CCFL, which sent me home because they were running an empty ER and probably just wanted to keep it that way. Great example of a difference in training venues: true teaching hospital with +100 plus patients coming/in ER during my 12 hour stay before getting admitted, versus 3 people noted on two late night ER visits to CCFL in a tony FL burb. Where would you rather train? I'd run for the U. Anecdotal as it is.

D712

 

[Mman]

No. IT happens to men and women. Perineal/Vaginal burning in women and Rectal burning in men. It is a dose related side-effect with about a 1% incidence at 4 mg which climbs to 2-4% at 8-10 mg IV. My "N" is way bigger than yours in this area.

My percentages reflect major discomfort/burning/pain and NOT mild irritation. Fortunately, this side-effect is short lived with most reporting pain/discomfort less than 5 min in duration.

You misread my post. I said it happens not infrequently. As in it happens quite a bit if you use it enough. I see it all the time if you ask patients with doses between 4-8 mg. Not all the time, but way more than 10% (anecdotally). Most patients just won't say anything about it.

 

[doctor712]

Sorry man. Since it happens "rarely" even at higher doses Nurses may not have seen it before. I limit my Dexamethasone dose in awake patients to 4 mg IV and this side-effect is very rare at that dosage. At 8 mg it is still uncommon but the incidence climbs significantly. ENT likes to give 10-12 mg IV to some of their patients in holding as a "pre-med" so I am familiar with RECTAL BURNING COMPLAINTS or "my ass-hole is on fire."

Simply diluting the higher dosages of Decadron in a 20 ml syringe and pushing it slowly over 60 seconds will decrease the incidence of major complaints to 1%.

Next time, if there ever is one, you can bet I'll be all over that suggestion! I recall 20MG, but I'll confirm on chart. Anyone have any guess why the itching/burning is limited to this one area of body? Interesting nonetheless...

D712

 

[BLADEMDA]

You misread my post. I said it happens not infrequently. As in it happens quite a bit if you use it enough. I see it all the time if you ask patients with doses between 4-8 mg. Not all the time, but way more than 10% (anecdotally). Most patients just won't say anything about it.

I disagree. It is a rare side-effect if MAJOR PAIN instead of minor discomfort is the end point. No way it is 10% as my N is in the tens of thousands if not more.

 

[Mman]

I disagree. It is a rare side-effect if MAJOR PAIN instead of minor discomfort is the end point. No way it is 10% as my N is in the tens of thousands if not more.

I'm referring to enough for the patient to mention it if you ask them. I'm not asking if it's incapacitating. They generally have midazolam in their system so even something major is going to be far less noticeable.

My N is in merely in the thousands. But I ask about it far more frequently than most people. Do you ask every patient? I certainly don't. But after the midaz kicks in I'll ask if they notice any strange sensations in their bottom and ask them to describe if they do.

 

[BLADEMDA]

Next time, if there ever is one, you can bet I'll be all over that suggestion! I recall 20MG, but I'll confirm on chart. Anyone have any guess why the itching/burning is limited to this one area of body? Interesting nonetheless...

D712

The cause of this phenomenon is still not fully understood. A phosphate ester which is part of this corticosteroid (dexamethasone sodium phosphate) might play an important role. The short nature of the pain could be due to the short duration needed to hydrolyse the compound to phosphate ions and dexamethasone

 

[BLADEMDA]

I'm referring to enough for the patient to mention it if you ask them. I'm not asking if it's incapacitating. They generally have midazolam in their system so even something major is going to be far less noticeable.

My N is in merely in the thousands. But I ask about it far more frequently than most people. Do you ask every patient? I certainly don't. But after the midaz kicks in I'll ask if they notice any strange sensations in their bottom and ask them to describe if they do.

I'm sure "strange sensations" in their ass-hole or Vagina may approach 10%. But, MAJOR PAIN (which I have seen and addressed) is very low especially with the 4 mg dosage IV.

 

[FiremedicMike]

Learned something new here today.. We only ever give it as a corticosteriod for respiratory issues, but our dose is a flat 10mg (other than pedi, which is weight based).

Should I ever encounter this in the future, I'll just grab the fentanyl and slam it home.. Thanks gang!

 

[doctor712]

The cause of this phenomenon is still not fully understood. A phosphate ester which is part of this corticosteroid (dexamethasone sodium phosphate) might play an important role. The short nature of the pain could be due to the short duration needed to hydrolyse the compound to phosphate ions and dexamethasone

I'd say 1 in 1,000,000 people on this planet can give an answer like yours. Thanks, Doc!

D712

 

[doctor712]

Learned something new here today...

I'm glad my as$-hole could take one for science and for the future of all as$-holes given the Decadron!

D712

 

[periopdoc]

Chalk another one up to the 4mg dose effect. I had the oddest sensation in my scrotum and anus. Not quite a burning or an itch. Almost an electrical sensation. Lasted less than a minute. It was hard to hold still. The urge to jump off the table and pull a full on Michael Jackson crotch grab on awkward pointe was almost overwhelming.

- pod

 

[FiremedicMike]

I'm glad my as$-hole could take one for science and for the future of all as$-holes given the Decadron!

D712

I reckon I owe you a beer or something

 

[baj8670]

Ever had a Kidney stone? You will not be impressed at 2 mg IV with a painful kidney stone. Some patients are just getting started at 2 mg IV with an acute stone.

Yep, I have a HX of stones least 3 a year, had litho done last month on a 12mm stone and believe you me, I believe the nurse said she gave me 1mg and I was @ bedside standing up dancing in pain,she finally came back in and said she could give me 1 more and it only took the edge off,they finally had to end u knocking me out w/ Fentanyl pain was so intense. This was my largest by the way, usually are 8-10mm

 

[doctor712]

Chalk another one up to the 4mg dose effect. I had the oddest sensation in my scrotum and anus. Not quite a burning or an itch. Almost an electrical sensation. Lasted less than a minute. It was hard to hold still. The urge to jump off the table and pull a full on Michael Jackson crotch grab on awkward pointe was almost overwhelming.

- pod

Yeah, hahaha, I got the electric anal Michael Jackson dance for a beat too.
D712

 

[doctor712]

I reckon I owe you a beer or something

Just leave some cash on the dresser.

D712

 

[pgg]

I'm sure "strange sensations" in their ass-hole or Vagina may approach 10%. But, MAJOR PAIN (which I have seen and addressed) is very low especially with the 4 mg dosage IV.

It still freaks people out, even if it doesn't cause pain. I just give the dexamethasone after induction and it's never an issue.

 

[tkim]

Ever had a Kidney stone? You will not be impressed at 2 mg IV with a painful kidney stone. Some patients are just getting started at 2 mg IV with an acute stone.

Toradol usually works better ... if your pharmacy still has it.

 

[dhb]

Toradol usually works better ... if your pharmacy still has it.

+1

 

[BLADEMDA]

It still freaks people out, even if it doesn't cause pain. I just give the dexamethasone after induction and it's never an issue.

Another advantage of doing your own cases. However, Dexamethasone AFTER sedation is usually well tolerated in the holding area or just prior to induction.

 

[BLADEMDA]

Ann Surg. 2003 Nov;238(5):651-60.
Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy: a randomized double-blind placebo-controlled trial.

Bisgaard T, Klarskov B, Kehlet H, Rosenberg J.
Source

Department of Surgical Gastroenterology 435, University of Copenhagen, Hvidovre Hospital, DK-2650 Hvidovre, Denmark. [email protected]

Abstract

OBJECTIVE:

To determine the effects of preoperative dexamethasone on surgical outcome after laparoscopic cholecystectomy (LC).
SUMMARY BACKGROUND DATA:

Pain and fatigue are dominating symptoms after LC and may prolong convalescence.
METHODS:

In a double-blind, placebo-controlled study, 88 patients were randomized to intravenous dexamethasone (8 mg) or placebo 90 minutes before LC. Patients received a similar standardized anesthetic, surgical, and multimodal analgesic treatment. All patients were recommended 2 days postoperative duration of convalescence. The primary endpoints were fatigue and pain. Preoperatively and at several times during the first 24 postoperative hours, we measured C-reactive protein (CRP) and pulmonary function, pain scores, nausea, and number of vomiting episodes were registered. Analgesic and antiemetic requirements were recorded. Also, on a daily basis, patients reported scores of fatigue and pain before and during the first postoperative week and the dates for resumption of work and recreational activities.
RESULTS:

Eight patients were excluded from the study, leaving 40 patients in each study group for analysis. There were no apparent side effects of the study drug. Dexamethasone significantly reduced postoperative levels of CRP (P = 0.01), fatigue (P = 0.01), overall pain, and incisional pain during the first 24 postoperative hours (P < 0.05) and total requirements of opioids (P < 0.05). In addition, cumulated overall and visceral pain scores during the first postoperative week were significantly reduced (P < 0.05). Dexamethasone also reduced nausea and vomiting on the day of operation (P < 0.05). Resumption of recreational activities was significantly faster in the dexamethasone group versus placebo group (median 1 day versus 2 days) (P < 0.05).
CONCLUSION:

Preoperative dexamethasone (8 mg) reduced pain, fatigue, nausea and vomiting, and duration of convalescence in patients undergoing noncomplicated LC, when compared with placebo, and is recommended for routine use.

 

[BLADEMDA]

http://www.feinberg.northwestern.edu/anesthesiology/welcome/Anesthesiology_article.pdf


Look at page 4. Plenty of evidence for giving LOW DOSE DECADRON preoperatively in holding.
Numerous studies referenced on page 4 stating safety and minimal side-effects.

 

[periopdoc]

I mix 4-8 mg with my induction propofol (all my patients get a sedating dose first). I can only imagine how hard the logistics of giving it 90 min before induction would be. My ambulatory patients might not even be in the building yet. Do you really believe that it is more effective if given in preop vs at induction?

-pod

 

[BLADEMDA]

I mix 4-8 mg with my induction propofol (all my patients get a sedating dose first). I can only imagine how hard the logistics of giving it 90 min before induction would be. My ambulatory patients might not even be in the building yet. Do you really believe that it is more effective if given in preop vs at induction?

-pod

No. But, in an ACT definitely more consistent. It works just as well when given at induction.

 

[ssmallz]

Sky's the limit

Chronic pain patients have been known to burn through entire hospital pharmacy stocks with a couple days' hard PCA use.

You ain't kiddin. I routinely give chronic pain pts 6mg of dilaudid prior to extubation for ex laps and lami's. It was a lot better in residency b/c we had access to suftenta. Run a sufenta drip and give 10mg of ketamine on induction. If titrated correctly they would wake up breathing 10-12/min and a smile on their face w/out supplementing other narcotics. In PP all we have is remi which is nice but since it goes away so quickly I gotta load up the dilaudid

 

[pgg]

You ain't kiddin. I routinely give chronic pain pts 6mg of dilaudid prior to extubation for ex laps and lami's. It was a lot better in residency b/c we had access to suftenta. Run a sufenta drip and give 10mg of ketamine on induction. If titrated correctly they would wake up breathing 10-12/min and a smile on their face w/out supplementing other narcotics. In PP all we have is remi which is nice but since it goes away so quickly I gotta load up the dilaudid

You ever give IV methadone at the start of those cases? It's too much of a hassle for me to get it now, but I liked it a lot for spine cases especially in the chronic opiate users.

 

[ssmallz]

You ever give IV methadone at the start of those cases? It's too much of a hassle for me to get it now, but I liked it a lot for spine cases especially in the chronic opiate users.

No, how do you dose it? What's the conversion factor from morphine

 

[Mman]

You ain't kiddin. I routinely give chronic pain pts 6mg of dilaudid prior to extubation for ex laps and lami's. It was a lot better in residency b/c we had access to suftenta. Run a sufenta drip and give 10mg of ketamine on induction. If titrated correctly they would wake up breathing 10-12/min and a smile on their face w/out supplementing other narcotics. In PP all we have is remi which is nice but since it goes away so quickly I gotta load up the dilaudid

only 10 mg of ketamine? I go with at least 50 and up to 100 mg for the chronic pain patients. Postop delirium probably less than 1% risk even at that dose.

 

[pgg]

No, how do you dose it? What's the conversion factor from morphine

I gave a single dose around induction, usually 10 or 20 mg. Mostly spine cases, but very satisfying in opioid-tolerant patients getting big general surgery whacks (on those occasions when I had an attending who was game).

I also liked to run ketamine in these patients for some extra NMDA goodness, usually 0.5 mg/kg as a load and either an infusion of ~3 mcg/kg/min through the case (or if I didn't feel like setting up a pump, ~10 mg boluses every 30 min or so). Sometimes more in the chronic pain patients.

Methadone has high oral bioavailability, much more than morphine, so the ubiquitous PO morphine --> PO methadone conversion charts need some modification when making IV --> IV estimates. On the PO side 4:1 morphine:methadone is pretty common, though some references will stretch that to 10:1 or higher when converting patients on >100-200 mg daily PO morphine, ie effectively a cap around ~30 mg methadone. As this is in the context of converting a chronic user over a period of days without any intervening surgical procedure, I'm not sure how useful those conversion guidelines are.

I think 3:1 is a reasonable guess, but the onset/duration/smoothness of it is different, plus there's the NMDA effects, so I don't know how useful that is either. Anecdotally I can say that 10-20 mg had satisfying results without problems with respiratory depression postop. I never got ballsy enough to go above 20 mg but some of my attendings did in the very opioid tolerant patients.


This is fairly recent

http://www.anesthesia-analgesia.org/content/112/1/13

but periop methadone isn't a new idea, it references this 30-year-old study, which I shall channel my inner Blade and paste


Gourlay, Geoffrey K. B.Pharm. Ph.D. *; Wilson, Peter R. Ph.D., F.F.A.R.A.C.S. +; Glynn, Christopher J. M.Sc, F.F.A.R.C.S. ++

Institution *Senior Hospital Scientist, Pain Management Unit
+Director, Pain Management Unit
++Senior Staff Specialist, Department of Anaesthesia & Intensive Care

Title Pharmacodynamics and Pharmacokinetics of Methadone during the Perioperative Period.[Article]

Source Anesthesiology. 57(6):458-467, December 1982.

Abstract The duration of postoperative pain relief was assessed in 23 general surgical or orthopedic patients administered 20 mg methadone as an iv bolus following induction of anesthesia. Nine patients (39%) were pain-free and required no additional analgesia for the control of their postoperative pain (Group 1). Eight patients (35%) required additional narcotic injections (Group 3) but the duration of adequate analgesia was 18.4 +/- 6.6 h (mean +/- SD). The remaining six patients (26%) requested non-narcotic analgesia (Group 2) for the control of their postoperative pain and the mean (+/-SD) time to the first supplementary dose was 26.5 +/- 4.8 h in these patients. The overall median duration of analgesia resulting from the 20 mg methadone was 27 h (n = 23). The mean (+/-SD) minimum effective analgetic blood methadone concentration was 30 +/- 11 ng/ml for the narcoticsupplemented group, and 33 +/- 12 ng/ml for the non-narcotic-supplemented group. The results obtained suggest there is a relationship between the blood methadone concentration and the control of postoperative pain.

Patients were sedated in the immediate postoperative period, but their respiratory rate was not depressed significantly (i.e., rate <10 breaths/min). In no case was it necessary to antagonize methadone with naloxone to initiate spontaneous respiration at the termination of the anesthetic. Nausea or vomiting occurred in 11 patients, but they responded to conventional antiemetic therapy.

Sequential blood samples were collected in 19 of the patients for estimation of methadone pharmacokinetics. The mean (+/-SD) methadone clearance was 178 +/- 100 ml/min (i.e., 2.7 +/- 1.7 ml [middle dot] min -1kg-1), while the terminal half-life was 35 +/- 22 h. These results suggest that methadone analgesia is related to the blood concentration of the drug and prolonged postoperative analgesia was consistent with the long half-life of the drug. There was a positive correlation between the methadone initial volume of distribution (76 +/- 49 1) and volume of distribution at steady-state (410 +/- 156 l) and body weight. Although there was a positive correlation between age of the patient and terminal half-life, no relationship existed between methadone clearance and age of the patient. Surprisingly, there was a highly significant negative correlation between methadone clearance and the minimum effective analgetic blood methadone concentration. The variables of duration of analgesia and minimum effective analgetic blood methadone concentration were subjected to multivariable regression analysis. The aim of this analysis was to provide equations to predict the value of these variables prior to surgery. The patient variables which had most influence included age, weight and the Eysenck Personality Inventory dimensions of neuroticism (N score), extroversion (E score), and social conformity (L score)

The authors conclude that methadone has the desirable pharmacokinetic (such as a long half-life and low clearance) and pharmacodynamic properties such that a single dose of 20 mg can result in prolonged postoperative analgesia.