Hypobaric Spinal Solution

[VentdependenT]

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Just curious as to what y'all are giving?

Occasionally we use it for hips or spinal (yup) surgery. So far its been 2cc of 0.5% bupivicaine diluted with 1cc of sterile saline (for a total of 3 cc) with 25ucg fentanyl and 200ucg of duramorph.

 

[epidural man]

Interesting post.

I just finished listening to the Audio Digest lecture by Julia Polluck at Virginia Mason.

She talks about using mepivicaine 1.5% (4cc) for the knee scope. I thought i would try sometime.

 

[VentdependenT]

Interesting post.

I just finished listening to the Audio Digest lecture by Julia Polluck at Virginia Mason.

She talks about using mepivicaine 1.5% (4cc) for the knee scope. I thought i would try sometime.

I don't think I've ever even seen a vial of mepiviaine.

 

[urgewrx]

Just curious as to what y'all are giving?

Occasionally we use it for hips or spinal (yup) surgery. So far its been 2cc of 0.5% bupivicaine diluted with 1cc of sterile saline (for a total of 3 cc) with 25ucg fentanyl and 200ucg of duramorph.

Interesting. I'm pretty sure pt's are comfortable with that cocktail. On what kind of spinal surgery you do spinals? How long do they last? For which level of coverage do you aim?

Why do you want hypobaric bupi instead of isobaric? Is it a positioning issue?

Why mix fent and duramorph? Doesn't intrathecal morphine work right away?

 

[VentdependenT]

Interesting. I'm pretty sure pt's are comfortable with that cocktail. On what kind of spinal surgery you do spinals? How long do they last? For which level of coverage do you aim?

Why do you want hypobaric bupi instead of isobaric? Is it a positioning issue?

Why mix fent and duramorph? Doesn't intrathecal morphine work right away?

One level low spinal stuff upon pt request or surgeon request. Last a couple of hours. Aim for the level of the surgery. Isobaric would work as well I suppose. Gotta keep in mind the curve o' the spine.

Hypobaric used for positioning: Hip--->stuff rises up into the hip. Spine, pt prone--->rises to the posterior of the subarachnoid space at that level. Or so we hope.

Fentanyl--->potentiate the local anesthetic. Immediate onset. Duramorph------>it may work right away but it doesn't PEAK for 45-60min. May not be good enough. Use it for post-op analgesia.

 

[coccygodynia]

Just did one today for an old lady needing an IM rod of the tibia - and used the same as you ... 2ml 0.5% Marcaine. Worked great. She also had a broken arm (same side) so I gave her 20mg of Ketamine prepositioning.

 

[BLADEMDA]

Just did one today for an old lady needing an IM rod of the tibia - and used the same as you ... 2ml 0.5% Marcaine. Worked great. She also had a broken arm (same side) so I gave her 20mg of Ketamine prepositioning.

Wait until you have done a thousand cases. Then, ten thousand more.
You will realize the whole Hypo/ISO/HYPER argument is pretty much B.S. for those with real world experience. It simply doesn't matter. I give 50-60 mg Propofol and use hyperbaric solutions 99% of the time. Thousands of cases with no increase in morbidity and the blocks work for hips just as well as knees.
I am not criticizing those that like to play with the baricity of their local; but just pointing out it is not necessary 99% of the time.

Blade

 

[VentdependenT]

Wait until you have done a thousand cases. Then, ten thousand more.
You will realize the whole Hypo/ISO/HYPER argument is pretty much B.S. for those with real world experience. It simply doesn't matter. I give 50-60 mg Propofol and use hyperbaric solutions 99% of the time. Thousands of cases with no increase in morbidity and the blocks work for hips just as well as knees.
I am not criticizing those that like to play with the baricity of their local; but just pointing out it is not necessary 99% of the time.

Blade

0.75% works fine for just bout everything I agree. We also are trying to use the reliability of the CSE with the motor benefits of a lido based epidural for our lower extremity total joints.

The faster folks move their leggies the faster they get out of the PAR. That means I can get my patient out of my room faster. Which ultimately means the surgeon will quit breathing directly down my neck.

 

[mick2003]

Just curious as to what y'all are giving?

Occasionally we use it for hips or spinal (yup) surgery. So far its been 2cc of 0.5% bupivicaine diluted with 1cc of sterile saline (for a total of 3 cc) with 25ucg fentanyl and 200ucg of duramorph.

For a simple guy who likes his spinals to sink, you're placing the spinal in the lateral position with the operative side up?

Thanks,
Mick

 

[MTGas2B]

0.75% works fine for just bout everything I agree. We also are trying to use the reliability of the CSE with the motor benefits of a lido based epidural for our lower extremity total joints.

The faster folks move their leggies the faster they get out of the PAR. That means I can get my patient out of my room faster. Which ultimately means the surgeon will quit breathing directly down my neck.

Short spinal Chloroprocaine

 

[VentdependenT]

Short spinal Chloroprocaine

Great for outpatient I would imagine even though I haven't seen anyone use it here. We are a bupivicaine people.

For inpatient, which our hips n' knees are (except for some of the same dayers), I fear cholorprocaine because it decreases the efficacy of the continuous epidural bupivicaine/fentanyl infusion we run. Then we get people asking if the epidural is in the right space, nurses calling, service calling, patient grumpy etc...

Never the less I totally overlooked this drug for that indication. I still had the fear of the TNS which happened back in the day when all the preservatives were in there.

 

[Lefty]

Chloroprocaine more of an issue causing adhesive arachnoiditis or TNS? I always thought TNS was mainly due to Lido?

Lefty

 

[SouthernGas]

The hyperbaric will result in more of an intrathecal spread c. more differential blockade vs. iso or hypo-baric (useful for ob/C-section but not in the ortho room where you don't want your block going up to T4)

(we use 2 -3 mL 0.5 % bup + 25 mcg fent. +/- epi)

 

[epidural man]

Chloroprocaine more of an issue causing adhesive arachnoiditis or TNS? I always thought TNS was mainly due to Lido?

Lefty

TNS can happen with any poison, i mean local anesthetic. It just happens the most frequent with lidocaine.

 

[epidural man]

I don't think I've ever even seen a vial of mepiviaine.

It's clear with some writing on it, and it has a cap that pops off.

 

[VentdependenT]

It's clear with some writing on it, and it has a cap that pops off.

Heeeyyyyyyyy-ooooooooooooo!!!!!!!!!!!

He'll be here all week folks.

 

[colchicine]

hey... just had a question in passing...

was just curious to see if anyone has ever used hyaluronidase or seen it used in the litterature for neuraxial/regional blocks like it's used for retrobulbars ???
If I remember correctly it's supposed to increase the spread of the local anesthetic and I guess improve the block ???

 

[BLADEMDA]

How many of your attendings have performed more than 5,000 spinals? How about 10,000? Mepivicaine and Chlorprocaine are not routinely used for spinal anesthetics and there are NO LARGE CONTROLLED studies recommending their routine use. Thus, I avoid these drugs at this time. When and If these studies occur I will consider using them.

As for Isobaric Bupivicaine (essentially preservative free bupivicaine primarily intended for Epidural use -not spinal) I have used it many it times. I don't see a great advantage over hyperbaric bupivicaine in the majority of cases.
Yes, the spread is less but the spinal block becomes more unpredictable in terms of length. Most of my cases don't need a 4 hour block.

My recommendation is to get very proficient using HYPERBARIC solutions in all types of situations/cases. These FDA approved local kits will be your bead and butter in the real world. You will know the length of the block and the spread of the local like the back of your hand after several hundred cases.
Then, when push comes to shove and you need a RELIABLE, PREDICTABLE spinal block for a case you will be ready.🙂

Blade

 

[VentdependenT]

What do you guys use for gyn cases and bootie cases of short duration?

Does bupivicaine 0.75% 1.5ml + 25ucg fent sound reasonable?

 

[rmh149]

What do you guys use for gyn cases and bootie cases of short duration?

Does bupivicaine 0.75% 1.5ml + 25ucg fent sound reasonable?

Yes. If they are admitted I use .25mg duramorph with 1.2-1.5cc .75 bupivicaine. For the vag hysterectomies I make them sit there for a couple of minutes before going supine.

Sometimes I will do a combined spinal epidural for the laparotomies/TAH's. Same dose as above, keep the epidural running with ropivicaine .1% with 5mcg/cc fentanyl till the morning. DC the epidural at 0630 after injecting 4mg duramorph.

Bootie cases of short duration, Lidocaine 5%.... 25-50mg.

 

[snowman8]

Yes. If they are admitted I use .25mg duramorph with 1.2-1.5cc .75 bupivicaine. For the vag hysterectomies I make them sit there for a couple of minutes before going supine.

Sometimes I will do a combined spinal epidural for the laparotomies/TAH's. Same dose as above, keep the epidural running with ropivicaine .1% with 5mcg/cc fentanyl till the morning. DC the epidural at 0630 after injecting 4mg duramorph.

Bootie cases of short duration, Lidocaine 5%.... 25-50mg.

Why not just use the Epidural for PCEA. That duramorph crap causes too much itching (although we sometimes use low dose naloxone gtts to help with this) and most pts still need something for breakthrough pain.

 

[rmh149]

Why not just use the Epidural for PCEA. That duramorph crap causes too much itching (although we sometimes use low dose naloxone gtts to help with this) and most pts still need something for breakthrough pain.

True. With my intrathecal/epidural narcotic orders I add Zyrtec 10mg after recovery and zofran q4h 4mg for 24 hours, after an 8mg load. If they still have itching, then I do the low dose narcan gtt. But most of my patients tell me they had very little itching.

 

[Planktonmd]

True. With my intrathecal/epidural narcotic orders I add Zyrtec 10mg after recovery and zofran q4h 4mg for 24 hours, after an 8mg load. If they still have itching, then I do the low dose narcan gtt. But most of my patients tell me they had very little itching.

Itching after spinal narcotics is not Histamine mediated !
Sedative Antihistamines can work because of their sedative action, but non-sedative antihistamines (like your Zyrtec) are not useful.
Ondansetron for Itching prophylaxis was shown to be ineffective in a recent study.
So, you might want to change your recipe!

 

[VentdependenT]

nubain

 

[Planktonmd]

Yes. If they are admitted I use .25mg duramorph with 1.2-1.5cc .75 bupivicaine. For the vag hysterectomies I make them sit there for a couple of minutes before going supine.

Sometimes I will do a combined spinal epidural for the laparotomies/TAH's. Same dose as above, keep the epidural running with ropivicaine .1% with 5mcg/cc fentanyl till the morning. DC the epidural at 0630 after injecting 4mg duramorph.

Bootie cases of short duration, Lidocaine 5%.... 25-50mg.

You might want to be careful using 5% Lidocaine Spinals since no one else does it any more, and there are documented cases of neurotoxicity with it!

 

[Planktonmd]

nubain

This one works.

 

[Planktonmd]

Itching after spinal narcotics is not Histamine mediated !
Sedative Antihistamines can work because of their sedative action, but non-sedative antihistamines (like your Zyrtec) are not useful.
Ondansetron for Itching prophylaxis was shown to be ineffective in a recent study.
So, you might want to change your recipe!

Suddenly, rmh149 is silent.😀

 

[VentdependenT]

I wouldn't touch 5% lidocaine. Ever.

 

[rmh149]

Itching after spinal narcotics is not Histamine mediated !
Sedative Antihistamines can work because of their sedative action, but non-sedative antihistamines (like your Zyrtec) are not useful.
Ondansetron for Itching prophylaxis was shown to be ineffective in a recent study.
So, you might want to change your recipe!

try it....

 

[dhb]

Just curious as to what y'all are giving?

Occasionally we use it for hips or spinal (yup) surgery. So far its been 2cc of 0.5% bupivicaine diluted with 1cc of sterile saline (for a total of 3 cc) with 25ucg fentanyl and 200ucg of duramorph.

Vent, do you think you get hypobaric with that mix? I looks more like an isobaric mix but the 1cc of saline gives you volume to cover more levels..

 

[Planktonmd]

try it....

Try what??
Zyrtec: I only try things that have some supporting evidence behind them.
Ondansetron: It was shown to be ineffective to prevent itching.
Lidocaine 5%: It's not standard of care anymore and there are case reports of Cauda Equina with it.
So, which one do I need to try?

 

[VentdependenT]

http://medind.nic.in/iad/t04/i1/iadt04i1p13.pdf

 

[rmh149]

Try what??
Zyrtec: I only try things that have some supporting evidence behind them.
Ondansetron: It was shown to be ineffective to prevent itching.
Lidocaine 5%: It's not standard of care anymore and there are case reports of Cauda Equina with it.
So, which one do I need to try?

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.

 

[The_Sensei]

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. I dont consider that a very strong study. Zofran is cheap and it covers PONV as well.....so why the hell not? 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.

Idiot

 

[johankriek]

I wouldn't touch 5% lidocaine. Ever.

try saying that on your boards.. LOL and they will paint a few scenarios in which they will make you touch 5 percent lidocaine. and then they will say.. i thought you said you would never use it.and then theywill say see you next year in the city of angels.. then when you walk out the senior examiner will say to the junior examiner. what an inflexible dingus.. i remember when i used to be like that.. and you will be back next year and guess what. you wont think like that anymore LOL

 

[rmh149]

Idiot

Is it possible for you to be more childish? Seriously, have you read over your posts? Is there ever a time when you are not acting like an ass?

 

[The_Sensei]

Is it possible for you to be more childish? Seriously, have you read over your posts? Is there ever a time when you are not acting like an ass?

Yes, when I am not responding or referring to you, nurse.

 

[rmh149]

Yes, when I am not responding or referring to you, nurse.

Wrong...I have seen you be an ass to many others that are not nurses. If this is the way you act in real life, it is good that you sit on a stool while the patient is sleeping...because you wouldnt make a dime if you had to win your patients trust and respect. People would definitely seek another doctor. You would have and empty waiting room.

 

[rmh149]

Ondansetron for Itching prophylaxis was shown to be ineffective in a recent study.
So, you might want to change your recipe!

Most of the studies done on prophylactic ondansetron was with only one injection of 4 or 8mg of ondansetron (some were before the intrathecal narcotic injection). I give an 8mg load, then 4mg every 4 hour for 24 hours. I have seen it work so I use it. It is just one of the weapons in my arsenal to fight against itching.

 

[VentdependenT]

try saying that on your boards.. LOL and they will paint a few scenarios in which they will make you touch 5 percent lidocaine. and then they will say.. i thought you said you would never use it.and then theywill say see you next year in the city of angels.. then when you walk out the senior examiner will say to the junior examiner. what an inflexible dingus.. i remember when i used to be like that.. and you will be back next year and guess what. you wont think like that anymore LOL

If thats the ONLY spinal agent in the hospital and for some reason the guy refuses GA for a procedure then fine I guess I'd give it on the boards. I'd warn the guy about TNS though.

We don't have 5%LIDO here. Or at North Shore. Or at Childrens Memorial.

 

[VentdependenT]

From some of the articles I've read and the larger pain books the pruritis from neuraxial morphine doesn't seem to be related to histamine release.

I've never tried giving zofran to someone with pruritis from neuraxial opoids here. We just give nubain 2.5mg and kapow.

 

[2ndyear]

I've read more than a few studies on zofran and pruritis from intrathecal opiates. Some are positive, some show no effect. Nubain is the winner in the literature that I've seen. But I routinely give zofran because it's cheap ($0.97) and safe. I also usually use fentanyl in addition to morphine and this causes itching as well.

 

[sdn1977]

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).

 

[BLADEMDA]

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.

The literature shows Zofran DOES work for itching due to intrathecal narcotics. The studies are under-powered but there a few in our literature. The problem is that Zofran for itching doesn't last very long and you need frequent doses (like your Q4) for Duramorph. I would just give one dose and start a low dose narcan or nubain drip.

As for which one is better the literature is unclear. It appears that if you go very low dose with the Narcan you counteract the itching without affecting the pain.

Can. Journal Aneasth 2000 Jan;47 (1) 33-7

Here are two more studies looking at narcan/nubain drips:

Reg Anesth Pain Med 1998 Sept-Oct;23 (5) 479-484
Anesth Analg 1996 March; 83 93) 641-647

As for me I usually start low dose Narcan infusion of around 0.1 ug/kg/hr AND order Zofran 4 mg IV Q 6 hours PRN (my pharmacy prefers Q 6 hour dosing and NOT Q4). The Nursing staff is busy and appreciates not having to give any Med Q 4 hours if possible.

For those who use Nubain for itching that is fine. I just have more experience with Narcan and know it works well.

Blade

 

[johankriek]

If thats the ONLY spinal agent in the hospital and for some reason the guy refuses GA for a procedure then fine I guess I'd give it on the boards. I'd warn the guy about TNS though.

.

Now you're talking!!

 

[Trisomy13]

MF DOOM.
Disgustingly good flows. Nice hip-hop.

Make sure you don't miss his album under the alias Viktor Vaughn as well. 👍

 

[dhb]

anybody care to comment on the baricity of the solution?

 

[rmh149]

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.

I guess I do have more flexibility with what I use at my hospital. I have no idea what kind of contracts they have...but they are OK with what I order as far as cost is concerned. Back in my Army days I was a pharmacy tech. I learned the benefit of consulting with the pharmacy gods.

 

[Planktonmd]

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.

I think you are just full of "you know what"!
You make statements about things you have no knowledge of and if someone points out your lack of knowledge and experience you respond in the same pointless manner: " I know what works for me" !
Then you go back and try to find semi intelligent explanations to your statements obviously from the INTERNET !
Here is again the three stupid things that you have said and never really supported by any evidence although you were given several chances:
1- You give Zyrtec for itching caused by intrathecal narcotics : Non sedative antihitamines don't work on that.
2- You give Ondansetron to prevent itching: It's a placebo effect as we now know.
3- You give Lidocaine 5% Spinals routinely: Obvious malpractice.

This is not because you are a nurse, it's just because someone might read your statements and think that you actually know what you are talking about and decides to follow you steps!

 

[Planktonmd]

The literature shows Zofran DOES work for itching due to intrathecal narcotics.

The evidence you mentioned is shaky and the most recent literature suggests that it DOES NOT WORK!
Now I know you have done hundreds of thousands or millions of spinals 🙂
But allow me to disagree on this one.
I tried Zofran a while ago and I think it's placebo for this indication.