Fine, you dont have to. But I know what works for me. I have read the studies that state zofran doesnt work...but they only looked at 18 or so patients. Plus, they only gave one dose. I dont consider that a very strong study. Zofran is cheap and it covers PONV as well.....so why the hell not give it around the clock? I have observed it work on a hell of alot more than 18 patients.
I used to run everyone on a low dose narcan gtt.....now I dont have to because I order zyrtec and zofran. So how can you possible say that it doesnt work? Try stepping outside the box?
And YES....I do believe MORPHINE intrathecally causes a histamine response leading to pruritis. I know there are other mechanisms behind prurites. But I also believe that itching after intrathecal morphine is in part due to a histamine response. So I cover it with zyrtec...and benadryl if need be. Yes, I know that the direct binding to the opioid recepter can also cause pruritis (which is why I also go to narcan)....but I dont think it is the only cause.
Nubain works too.....I just go to narcan first.
Since most hospital cases are reimbursed based on a drg - the actual "cost" is tied to many things. Its difficult to asses the acutal "cost" of the drug, particularly since within pharmacy we are changing from AWP (average wholesale price) to AMP (average manufacturer price) in which case - the actual cost may be significant. Anytime you increase the "cost" you decrease profit from the drg reimbursement.
Drug pricing within hospitals is a negotiated contractual annual cost and often bundled & tied with other drugs or IV fluids. If your hospital uses zyrtec as its H-1 blocker as a formulary choice - it will be inexpensive. Mine does not, so Zyrtec is not even available & will be automatically substituted to the forumulary choice.
Likewise, ondansetron is an extremely expensive drug (granted less expensive than its brand name counterpart, but expensive nonetheless) - even generically. We allow its unlimited use in chemo infusion patients and "watch" its use in other settings - post op for one.
If we found it was being used routinely - we'd start to intervene because its just too expensive for our drg reimbursement, unless we have a drg which supports it use - antineoplastic infusions for the most part. We are asked & submit our drug pricing based on drgs on an annual basis - this is only one part of what is negotiated in the reimbursement, but pharmacy is one of the largest "cost centers" within a hospital - there is NO reimbursement for nursing - PACU - med-surg. So, many of the other cost centers must cover this expense. Each case may seem a small expense - but, over time - it builds up to thousands of dollars.
I'd agree with Plankton - the itching following a spinal opioids is not caused by histamine release & the relief the pt experiences with an antihistamine is due to its sedative effects. Numerous studiees support this.
You may BELIEVE it is due to a histamine release, but studies have shown it is caused by several complex mechanisms. Current research shows that central causes of prurities are more important than peripheral causes. It may be due to the cephalad spead of the drug in the CSF & its action on the u-receptors & central serotonin type 3 receptors in the spinal cord & medulla.
Your experience with using a 24 hour course of ondansetron may be due to having it reach the levels in the time required to have modulated the central serotonin receptors - but at what price?
I'm not sure how you'd even evaluate how "cheap" zofran is - its difficult for hospital pharmacists to evaluate it unless we can see the whole annual picture of cost, rebates & reimbursements.
Your particular situation may have more flexibility than mine, but we do not routinely allow the use of either of these agents post-op unless the pt fails standard protocol therapy.
We also do not stock 5% lido nor do we use hyaluronidase anymore. Both used to be routine, but have fallen out of favor. We used to use hyaluronidase routinely for hypodermoclysis (now that is a technique from the OLD days!!!), but only use it for knees now (Hyalgan).
