Hypobaric Spinal Solution

[BLADEMDA]

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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.

Plankton,

I resprect your opinion. I have not been impressded with Zofran for this indication. I prescribe it as a secondary treatment along with my low dose Narcan drip (or in your case Nubain). But, the literature is divided on its effectiveness. I don't put a lot of stock in the LATEST study just the best ones.

Here are a few that support Zofran:

J Anesth 2007; 21 (2) 159-63 Epub 2007 May 30
Anesth Analg 2002 Dec;95 (6):1763-6
Anesth Analg 2000 Jul;91 91) 172-5

Here are two that state Zofran doesn't work for Pruritus:

Acta Anaesthesiol SCand 2006 Feb;50 (2):239-44
J Clin Anesth 2002 May;14 (3) 183-186


So, the jury is still out. Again, I have not been impressed with Zofran as the primary agent for intrathecal induced itching. But, I do add it as a secondary agent.

Blade

 

[rmh149]

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.

Why dont you post the most recent literature since you feel so strongly about it.

I would really hate for people to read your posts and think you know EVERYTHING you are talking about.

 

[Planktonmd]

Why dont you post the most recent literature since you feel so strongly about it.

I would really hate for people to read your posts and think you know EVERYTHING you are talking about.

I definitely know EVERYTHING I talk about.
You know why?
I am a board certified anesthesiologist with years of experience.
I am a consultant in anesthesiology and that should be good enough for someone like you.
If you read my post and understand it you will realize that it's not only about recent literature, it's about you advocating Dangerous practices ( Lidocaine 5% Spinals), or Unscientific cook book treatments like giving Zyrtec for post spinal itching.

 

[rmh149]

I definitely know EVERYTHING I talk about.
You know why?
I am a board certified anesthesiologist with years of experience.
I am a consultant in anesthesiology and that should be good enough for someone like you.
If you read my post and understand it you will realize that it's not only about recent literature, it's about you advocating Dangerous practices ( Lidocaine 5% Spinals), or Unscientific cook book treatments like giving Zyrtec for post spinal itching.

I'm still waiting for your spectacular literature that says zofran is just a placebo.

 

[BLADEMDA]

I'm still waiting for your spectacular literature that says zofran is just a placebo.

RMH,

I think I found the study Plankton was refering to about Zofran:

Anesth and Analgesia 2007 Feb;104 (2) 421-424

This was another SMALL study of about 40 patients per Group. Zofran was no more effective than placebo (saline). Again, the jury is still out on Zofran as there are studies which support its use and some that claim its worthless for intrathecal induced itching.

Blade

 

[Planktonmd]

I'm still waiting for your spectacular literature that says zofran is just a placebo.

If you want to learn you can search the literature yourself.
I don't think you want or can learn though.

 

[rmh149]

RMH,

I think I found the study Plankton was refering to about Zofran:

Anesth and Analgesia 2007 Feb;104 (2) 421-424

This was another SMALL study of about 40 patients per Group. Zofran was no more effective than placebo (saline). Again, the jury is still out on Zofran as there are studies which support its use and some that claim its worthless for intrathecal induced itching.

Blade

Thank you.

 

[rmh149]

OK, making changes to my recipe.

I am going to stick with Zofran around the clock. 8mg load and 4mg q4h, as the literature shows just 8mg doesnt work.

Keep doing PRN low dose narcan gtt.

Keep doing PRN nubain.

After talking to the nurses, half go to the narcan, the other half go to nubain.

No more zyrtec 10mg. I originally thought the combonation zyrtec and zofran was helpful, but I believe the zofran will be just as good without the zyrtec. Yes Plankton, I am convinced.

 

[dhb]

I am going to stick with Zofran around the clock. 8mg load and 4mg q4h, as the literature shows just 8mg doesnt work.

I don't know how cheap your zofran is but it can't be cheap enough to justify that regimen:
In our hospital (socialized medicine drug cost are negotiated on a national level and are generaly much cheaper than in the us) it cost 13$ per 4mg vial which would equate to 78$ the first 24h...

anybody with a comment on the baricity 🙂 ?

 

[rmh149]

I don't know how cheap your zofran is but it can't be cheap enough to justify that regimen:
In our hospital (socialized medicine drug cost are negotiated on a national level and are generaly much cheaper than in the us) it cost 13$ per 4mg vial which would equate to 78$ the first 24h...

anybody with a comment on the baricity 🙂 ?

Now that zofran went generic it is less than $1.50 per 4mg vial at my hospital. So for 24 hours it is around $12.00.

 

[Noyac]

rmh,

Your hospital cost for zofran may be low but your pts cost definitely isn't. Its not only about how much something costs the hospital but the burden it puts on our pts and the healthcare system. Your use of large doses of zofran must cost your pts a few hundred bucks in my best guess. Sure the insurance may cover it but just think how much it would cost if everyone did this. It is also not just the medicines cost but the burden on the nursing staff and the pharmacy and everyone else involved to give a useles medicine every 4 hours. Thankfully, most of us know that zofran is not supported well in the literature for this use and that narcan and nubain are the gold standards for intrathecal narcotics and puritis.

I use nubain almost exclusively. I rarely have a nurse tell me they had to give more than 2 doses and they are usually at least 6 hours apart. My floor nurses were routinely reaching for benadryl for the puritis even without an order 😱. Now after some training they are impressed with nubain. And it adds some analgesic benefits as well. And another thing, the puritis rarely lasts more than 12 hours but your giving zofran for 24 hours. Why?

 

[Anesthesia1979]

Zofran cost at our hospital is $0.71
Zofran cost to the patient.... ???

It's cheaper than reglan, decadron, benadryl, and any other anti-emetic at our hospital. It has gone from only Anesthesia able to prescribe to the anti-emetic of choice.

 

[sdn1977]

Now that zofran went generic it is less than $1.50 per 4mg vial at my hospital. So for 24 hours it is around $12.00.

I tried to explain....its not the cost of just one drug we look at. It is the cost of the whole procedure.

Each dose of that $1.50 drug will bill out to the patient anywhere between $28-$35 per dose (heck - an apap 325mg bills out at $3, a vicodin - $4-5).

But - that is not this issue since very few patients are actually cash paying & if they are - their bills are negoitiated. These fees are used to absorb all the non-cost center fees (PACU nurses for example) which can't bill for their time. No one every pays them - they're used as negotiation tools.

So - over time, we look at the non-cost center generating money areas & will divide that among those depts which can generate revenue. If we can save money - great, but that won't get the price down. If you choose to use zofran when a few cents worth of nubain will do the same trick - you are losing $$ on your drg reimbursement (which covers all your Medicare & HMO pts).

While we all have to function under drg reimbursement, if you want the hospital to stay afloat, you have to decrease the costs associated with that drg - give the least expesive drug you can with the fastest possible discharge available.

Thats why we use ondansetron almost exclusively in chemo outpt & versed in outpt surg. It gets them in & out fast. Likewise.....Lovenox (or any of the other equivalent drugs) is far more expensive than heparin, but it can & is being used safely & effectively with first dose in ER after DVT dx & subsequent doses @ home with follow up with PCP. It maximizes the DVT reimbursement while minimizing the cost. The cost of the drug gets shifted to the pts outpt drug reimbursement plan, which is separately administered. It may not be the very best medicine, but it is what is current right now.

The whole scenario changes if you're classified as a 305 hospital which is why you have the suits in charge of the money negotiation. That is when cost/reimbursements & shifts get complicated.

 

[flgasman]

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?

its usually used for hip because you cant position the patient on the side of a fractured hip therefore the fractured hip is higher and the hypo rises

 

[Noyac]

its usually used for hip because you cant position the patient on the side of a fractured hip therefore the fractured hip is higher and the hypo rises

Please read the quote. They are now talking about spinal surgery. You don't really think that a veteran doesn't know what hypobaric spinals are for now do you?