IV Tylenol Offirmev

[Hockeyguy]

We have had IV Tylenol on formulary for about 4 years. It started out at around 10 dollars and went to 36. The company got bought out so they are blaming the dramatic price increase on that. Our pharmacy and admin has pulled it - can't say I blame them it was a pretty ridiculous increase. That being said our group liked it and we did find it effective in reducing PONV, improving pain scores and speeding up discharge. We just don't see the same benefit when we give it PO as a premed. Has any else had it yanked? If so were you able to negotiate a more reasonable price? I asked the rep not to call on us until we got at least the price they give to Kaiser which I believe is in the teens. Thoughts...

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[deleted126335]

We give less of it. Still use it in the OR, but total joint patients who used to be getting 4 doses total are now getting 1-2.

 

[Ignatius J]

We give less of it. Still use it in the OR, but total joint patients who used to be getting 4 doses total are now getting 1-2.

I am not a fan. I don't see a difference in IV versus PO.

 

[urge]

Never saw a difference between patients who had it vs. patients who did not.

 

[jwk]

We use it routinely. Our PACU nurses swear by it, and it's an integral part of our multi-modal approach. Our orthopedic surgeons love it, ask for it, and order it post-op. PO tylenol pre-op does nothing IMHO.

We were not happy about the price increase, but honestly, compared to other patient charge items or supplies, it's a drop in the bucket. Ever price a microscope drape or the draping system for the damn DaVinci? Or even just a single implantable screw for any type of procedure? It's waaaaaaaaaayyyyyyyyyyy more than $36.

 

[urge]

We use it routinely. Our PACU nurses swear by it, and it's an integral part of our multi-modal approach. Our orthopedic surgeons love it, ask for it, and order it post-op. PO tylenol pre-op does nothing IMHO.

We were not happy about the price increase, but honestly, compared to other patient charge items or supplies, it's a drop in the bucket. Ever price a microscope drape or the draping system for the damn DaVinci? Or even just a single implantable screw for any type of procedure? It's waaaaaaaaaayyyyyyyyyyy more than $36.

Our nurses do the same. They ask for it on patients who just had it, or who just had ketorolac. They just want to give it whether it is needed or not.

 

[urge]

I am not a fan. I don't see a difference in IV versus PO.

That is what the literature supports.

20% morphine reduction when IV is used vs PO. ( ie, 16mg vs. 20mg)
Same opioid side effects.
Same pain score.
Same patient satisfaction.

It's very easy for me to understand this. The drug barely works, IV or PO. I don't ever take it at home because it just does not work.

So, you are giving a $36 IV drug so you can save a few cents on morphine.

 

[Planktonmd]

It works great and sometimes you can skip the opiates all together in PACU which is why PACU nurses love it

 

[urge]

It works great and sometimes you can skip the opiates all together in PACU which is why PACU nurses love it

What kind of procedures are you talking about?

 

[Promethean]

It's very easy for me to understand this. The drug barely works, IV or PO. I don't ever take it at home because it just does not work.

So, you are giving a $36 IV drug so you can save a few cents on morphine.

There are more benefits to opioid-sparing strategies than just the costs of the drugs. 20% reduction is 20% reduction. Now, layer that with other narcotic sparing strategies, like ketamine, other analgesics, etc and maybe you can see 50% or more.

But then, I (and the literature) disagree with you about the efficacy of the drug. Acetaminophen does work well when it is used for the correct indications. It is an extremely useful adjuvant for many kinds of pain, such as headache, where opioids are relatively unhelpful, without the severity of side effects associated with opiates.

Having seen loved ones whose lives were ruined or ended by opiate addiction colors my opinions, I'm sure. But I think that the current epidemic of prescription drug abuse and overdose deaths from prescribed opiates probably supports an excess of caution with regard to those drugs. They have their place, and when it is appropriate, I will resort to them. But $36 to reduce exposure to them by 20% is a bargain, in my opinion.

 

[Promethean]

I worked in a pediatric OR setting where there was great excitement when this drug became available. There was absolutely a profound post-op difference between children undergoing complete oral rehabilitations including multiple extractions under anesthesia when they were provided with an intraoperative dose of IV tylenol. Less opioid needed during the case, sometimes none at all in PACU, some kids able to be sent home with ibuprofen rather than opiate prescriptions. In a patient population where there is HIGH likelihood that the patient's drugs would be diverted to parents (2 and 3 year olds who needed all their baby teeth pulled due to decay, who had to have child protection services involved to get them to the dentist in the first place,) opiate sparing was not just a notional benefit.

 

[Ignatius J]

I worked in a pediatric OR setting where there was great excitement when this drug became available. There was absolutely a profound post-op difference between children undergoing complete oral rehabilitations including multiple extractions under anesthesia when they were provided with an intraoperative dose of IV tylenol. Less opioid needed during the case, sometimes none at all in PACU, some kids able to be sent home with ibuprofen rather than opiate prescriptions. In a patient population where there is HIGH likelihood that the patient's drugs would be diverted to parents (2 and 3 year olds who needed all their baby teeth pulled due to decay, who had to have child protection services involved to get them to the dentist in the first place,) opiate sparing was not just a notional benefit.

I respectfully disagree. No one should have to take home narcotics after getting teeth pulled. Maybe wisdom teeth, but even then. I had my wisdom teeth pulled back in the day with just local. Took ibuprofen for a day or so and I was fine. Toradol + short acting narcotic intraoperatively has worked just fine for me in these cases.

 

[urge]

Less opioid needed during the case, sometimes none at all in PACU, some kids able to be sent home with ibuprofen rather than opiate prescriptions.

Why were they not sent home on acetaminophen?

Could it be that it barely works? Maybe? 🙂

Why were these kids not getting ketorolac in the OR?

 

[Ignatius J]

There are more benefits to opioid-sparing strategies than just the costs of the drugs. 20% reduction is 20% reduction. Now, layer that with other narcotic sparing strategies, like ketamine, other analgesics, etc and maybe you can see 50% or more.

But then, I (and the literature) disagree with you about the efficacy of the drug. Acetaminophen does work well when it is used for the correct indications. It is an extremely useful adjuvant for many kinds of pain, such as headache, where opioids are relatively unhelpful, without the severity of side effects associated with opiates.

Having seen loved ones whose lives were ruined or ended by opiate addiction colors my opinions, I'm sure. But I think that the current epidemic of prescription drug abuse and overdose deaths from prescribed opiates probably supports an excess of caution with regard to those drugs. They have their place, and when it is appropriate, I will resort to them. But $36 to reduce exposure to them by 20% is a bargain, in my opinion.

Question is does the difference between 20mg vs. 16mg make a difference in patient outcome or satisfaction? It apparently does not.

 

[BLADEMDA]

Unfortunately, there has not been a full evaluation of the economic impact of IV acetaminophen in the United States. However, in an era of cost-effectiveness, IV acetaminophen does not appear to have any clinical benefit over oral and rectal acetaminophen except in patients who require IV administration. Given the high drug cost and inconsistent benefit, IV acetaminophen should be reserved for patients who cannot take acetaminophen via oral or rectal routes and patients who cannot tolerate the other IV non-opioid analgesics.

http://www.clevelandclinicmeded.com/medicalpubs/pharmacy/pdf/Clinical-Pharmacy-Forum-I-2.pdf

 

[BLADEMDA]

IV acetaminophen was marketed on the premise that it could serve as a foundation for “multi-modal” pain control by achieving more rapid and higher plasma concentrations than the oral and rectal formulations. Theoretically, this would reduce opioid use and therefore reduce opioid related adverse events. However, this hasn't exactly panned out in clinical studies. A meta-analysis by McNicol and colleagues found a whopping reduction of 1.3 mg morphine equivalent at 6 hours among 154 post-operative patients in whom IV acetaminophen was added. Not surprisingly, they found no decrease in opioid-related adverse events.1 These findings were replicated in another meta-analysis by Remy and colleagues who found a 9 mg morphine equivalent reduction at 24 hours among post-operative patients. Again, there was no difference in opioid-related adverse events between groups.2
So why the disconnect? Pharmacokinetic studies have demonstrated a clear difference between the oral and IV routes of administration (see figure below). Product promotional materials suggest that the threshold for analgesic effects is 16 mcg/ml (or 16 mg/L), and the threshold for antipyretic effects is 5 mcg/mL. However, these thresholds are based on small studies and pharmacokinetic models.3,4 There are numerous trials evaluating escalating doses of acetaminophen achieving higher serum concentrations, but lacking additional analgesic benefit.5-7 These findings were validated in a large Cochrane review of nearly 6,000 surgical patients that failed to demonstrated a clear dose-response relationship.8 Additionally, even though it appears that peak acetaminophen concentrations are reached rapidly with the IV formulation, there is a “lag-time” of at least 60-90 minutes for analgesic effect.9
Some proponents of IV acetaminophen may argue that in patients who are NPO, there aren't really many options for non-opioid pain control, especially when the bleeding risks of parenteral NSAIDs might outweigh any benefit. The rectal formulation of acetaminophen may be dismissed as “simply undignified.” I would argue that it’s equally (if not more) offensive to use a drug that is approximately 50-fold more costly than its rectal form, 13-fold more costly than an opioid, and 1000-fold more costly than its oral form.




http://empharmd.blogspot.com/2014/07/iv-acetaminophen-for-pain-management-in.html

 

[urge]

Unfortunately, there has not been a full evaluation of the economic impact of IV acetaminophen in the United States. However, in an era of cost-effectiveness, IV acetaminophen does not appear to have any clinical benefit over oral and rectal acetaminophen except in patients who require IV administration. Given the high drug cost and inconsistent benefit, IV acetaminophen should be reserved for patients who cannot take acetaminophen via oral or rectal routes and patients who cannot tolerate the other IV non-opioid analgesics.

http://www.clevelandclinicmeded.com/medicalpubs/pharmacy/pdf/Clinical-Pharmacy-Forum-I-2.pdf

Glad to see there is some common sense at the Clinic.

I often wonder how people in practice cannot see stuff for themselves.

 

[btbam]

Our pharmacy only lets us use it for T+As (peds hospital)

 

[BLADEMDA]

Our pharmacy only lets us use it for T+As (peds hospital)

I don't have a problem with Offirmev; I own the stock of the company which sells it. The drug is safe and somewhat effective but it is expensive for the what you actually get out of it. At $36 a dose I can see why many hospital formularies have said "no thanks."

 

[Planktonmd]

What kind of procedures are you talking about?

All kinds: GYN, Breast, Hernia, Colectomy...

 

[Planktonmd]

IV Acetaminophen given during the surgery has a very significant opiate sparing effect in PACU to a point that you could see a patient getting zero opiates after a hysterectomy or breast surgery.
An added advantage is that It does not interfere with platelets function so it does not scare some surgeons as Ketoralac does.
Integrating this medication as a part of a multimodal approach to post op analgesia is very helpful especially for out patient surgery where fast recovery and decreased opiate side effects are very important.

 

[pgg]

Last I heard we're still paying $10.

 

[norwood]

Unfortunately, there has not been a full evaluation of the economic impact of IV acetaminophen in the United States. However, in an era of cost-effectiveness, IV acetaminophen does not appear to have any clinical benefit over oral and rectal acetaminophen except in patients who require IV administration. Given the high drug cost and inconsistent benefit, IV acetaminophen should be reserved for patients who cannot take acetaminophen via oral or rectal routes and patients who cannot tolerate the other IV non-opioid analgesics.

http://www.clevelandclinicmeded.com/medicalpubs/pharmacy/pdf/Clinical-Pharmacy-Forum-I-2.pdf

Which begs the question - is there a study comparing Ofirmev to rectal acetaminophen? Sure, I'd rather give an IV drug than a suppository, but it's a lot easier to justify the price if it's also clinically better.

 

[BLADEMDA]

 

[BLADEMDA]

 

[Promethean]

Why were they not sent home on acetaminophen?

Could it be that it barely works? Maybe? 🙂

Why were these kids not getting ketorolac in the OR?

Multiple extractions. Sometimes all the teeth in their head. Sometimes, they would ooze a fair amount of blood, despite the sutures. Ketorolac = increased bleeding, therefore IV tylenol. Sent home with oral ibuprofen because the anti-inflammatory effect is beneficial given the trauma... once hemostasis has been established. Intraoperatively, suppression of inflammation was accomplished with IV dexamethasone.

Ketorolac was routinely given when bleeding wasn't an issue, such as when teeth could be saved by multiple caps, resins, and fillings.

The other folks who love IV tylenol, for the same reason, are the ortho docs.

Again, tylenol does indeed work when used for indications that it is good for. It is useless as an anti-inflammatory, no argument. So, don't try to use it as one, and you will find that its analgesic effects are not as minimal as you claim.

Children wake up from dental cases spitting and crying more often than not and require doses of opiate in the PACU. Once we got IV tylenol, that happened less. Still happened, but less drama, less blood, less screaming. Yeah, it is just anecdata, but it was pretty convincing to witness.

 

[Promethean]

I respectfully disagree. No one should have to take home narcotics after getting teeth pulled. Maybe wisdom teeth, but even then. I had my wisdom teeth pulled back in the day with just local. Took ibuprofen for a day or so and I was fine. Toradol + short acting narcotic intraoperatively has worked just fine for me in these cases.

I don't see what I said that you could be respectfully disagreeing with?

I am saying that the use of IV tylenol helped reduce the number of kids who got roxicet for home, and that this is a very good thing. I also had my wisdoms out with just local, and I only used tylenol and ibuprofen post mastectomy. But I am not a 3 year old who has had to have every one of his teeth pulled. It is possible that I have better coping mechanisms (on my good days) for moderate amounts of discomfort.

The attendings for those patients would sometimes decide that some amount of opiate was warranted for those cases, and I am not qualified to disagree with them on that. I simply note that the frequency of take home opiate prescriptions seemed to drop even further once patients reported less pain in PACU.

 

[Ignatius J]

Multiple extractions. Sometimes all the teeth in their head. Sometimes, they would ooze a fair amount of blood, despite the sutures. Ketorolac = increased bleeding, therefore IV tylenol. Sent home with oral ibuprofen because the anti-inflammatory effect is beneficial given the trauma... once hemostasis has been established. Intraoperatively, suppression of inflammation was accomplished with IV dexamethasone.

Ketorolac was routinely given when bleeding wasn't an issue, such as when teeth could be saved by multiple caps, resins, and fillings.

The other folks who love IV tylenol, for the same reason, are the ortho docs.

Again, tylenol does indeed work when used for indications that it is good for. It is useless as an anti-inflammatory, no argument. So, don't try to use it as one, and you will find that its analgesic effects are not as minimal as you claim.

Children wake up from dental cases spitting and crying more often than not and require doses of opiate in the PACU. Once we got IV tylenol, that happened less. Still happened, but less drama, less blood, less screaming. Yeah, it is just anecdata, but it was pretty convincing to witness.

Toradol increasing bleeding is dogma and has been shown to be a myth in a good-sized meta-analysis of RCTs. It is a great drug and much better than Ofirmev. Not to mention much cheaper. The literature supports this.

http://www.ncbi.nlm.nih.gov/m/pubmed/24572864/

 

[pgg]

Ketorolac = increased bleeding, therefore IV tylenol.

I like IV acetaminophen, but I've never really believed this.

About 5 or 6 months ago I started giving ketorolac to just about everyone undergoing outpatient surgery ... as we're rolling to the OR. Haven't needed to take anyone back to the OR yet.


This has a pleasant side effect too - since I'm not a big fan of preop Versed, the most overused drug in anesthesia, I rarely give it. Now when the RN says in a cheery voice something along the lines of "your bartender's going to give you a little something-something now" I don't have to explain to the patient why I'm not putting anything in the IV. I get the benefits of preop ketorolac and a placebo sedation effect. 🙂

 

[Planktonmd]

Toradol increasing bleeding is dogma and has been shown to be a myth in a good-sized meta-analysis of RCTs. It is a great drug and much better than Ofirmev. Not to mention much cheaper. The literature supports this.

http://www.ncbi.nlm.nih.gov/m/pubmed/24572864/

Many surgeons still believe it does increase bleeding, which means if the patient bleeds they will blame you for it regardless of what you might think is truth or fiction.

 

[Ignatius J]

Many surgeons still believe it does increase bleeding, which means if the patient bleeds they will blame you for it regardless of what you might think is truth or fiction.

I have no problem having a nice, professional discussion with them. I think I owe it to them for the sake of patient care. The few who do care have been more than willing to hear me out.

 

[deleted171991]

It works great and sometimes you can skip the opiates all together in PACU which is why PACU nurses love it

Is it better than toradol?

P.S. It seems I was a bit late with the question. 🙂

 

[Promethean]

Well, I am a just a pre-med who happens to have an RN. I can only report what I have seen, and then defer to the voices of those more qualified than myself in these matters. Thanks for letting me join in, to that degree.

 

[pgg]

I have no problem having a nice, professional discussion with them. I think I owe it to them for the sake of patient care. The few who do care have been more than willing to hear me out.

That's a nice theory, but these discussions only tend to happen when surgeons are cranky about something, and however nice and professional you are, the cranky ones just aren't in a receptive mood. I guess you could bring up the subject in advance, but that seems wrong for another reason - why should we ask them permission to use anesthetic and analgesic drugs?

I'd rather not have a discussion at all, and let the wakeups do the talking re: the quality of my anesthetic. If a tree falls in the forest, and a patient does well, and the surgeons don't read the anesthetic record, does the preop ketorolac they don't know about make a sound? Note that I'm not advocating deceiving them. But I don't tell them how much propofol or fentanyl I give, either.


I have had one surgeon get irritated with my pre-emptive ketorolac. Late in an outpatient lap chole she gave me "permission" to give it. I acknowledged her words but didn't move, and I guess that non-movement tipped her off that I'd already given it. She asked, I said yes, and she got mad, and started lecturing about how it's her decision that she need to assess the gall bladder bed first, because bleeding.

Of course, she had also criticized my fluid management, and at one point felt the need to tell me that "rocuronium lasts one hour" ... I could refer her to that RCT meta-analysis but it's not like she'd read it.

These are exactly the sort of discussions I prefer not to have with exactly the sort of surgeons I prefer not to talk to. It's a non-issue with the rest.

Is it better than toradol?

Acetaminophen + ketorolac is better than ketorolac. 🙂

Ketamine + acetminophen + ketorolac is even better. 😀

 

[deleted171991]

These are exactly the sort of discussions I prefer not to have with exactly the sort of surgeons I prefer not to talk to. It's a non-issue with the rest.

+1

 

[BLADEMDA]

I think multi-modal analgesia is great for the patient. Do I think IV Tylenol is worth $36? No. The IV formulation is just slightly better than the $1.0 PO version.

How about the following:

1. Ketamine (0.15 mg/kg-0.25 mg/kg)
2. Dexamethasone 0.1 mg/kg
3. Toradol 30 mg (15 mg for the elderly)
4. Tylenol P.O.

Items 1-4 would likely cost less than $5.0 combined and work significantly better than one bottle of IV tylenol at $36

http://www.ncbi.nlm.nih.gov/pubmed/23602757

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1388093/

http://bja.oxfordjournals.org/content/early/2012/12/04/bja.aes431.full

http://www.ncbi.nlm.nih.gov/pubmed/25122642

 

[pgg]

I think multi-modal analgesia is great for the patient. Do I think IV Tylenol is worth $36? No. The IV formulation is just slightly better than the $1.0 PO version.

How about the following:

1. Ketamine (0.15 mg/kg-0.25 mg/kg)
2. Dexamethasone 0.1 mg/kg
3. Toradol 30 mg (15 mg for the elderly)
4. Tylenol P.O.

Items 1-4 would likely cost less than $5.0 combined and work significantly better than one bottle of IV tylenol at $36

Until I get the email from the beancounters that IV acetaminophen costs too much for routine use, I'm going to keep using it.

My usual approach now (adults) is
1. Ketamine 0.5 mg/kg IV with induction (0.25 mg/kg for short or non-painful cases)
2. Dexamethasone 4 mg IV with induction
3. Ketorolac 30 mg with induction, or earlier if I have it drawn up already
4. Tylenol IV after the antibiotics

I do reduce the ketorolac dose for old people. I used to give fentanyl with induction to blunt laryngoscopy, now I use esmolol, and hold off on opiates as long as I can. Occasionally I get away with zero opiate, but usually I feel a need for some around wakeup. It's worlds better than what I used to do, which was occasional ketamine, no IV acetaminophen, early opiate, and ketorlac late in the case. I've always liked ketamine, but only recently did I start giving it to just about everyone.

Lately I've sometimes been adding 2-3 g of magnesium to the IV bag. I'm not sure how much good it's doing though.

Maybe in a couple years I'll be doing something totally different. 🙂


Edit - I should qualify the above by saying that if I'm working with a resident, I generally let them do what they want, within reason. As a group they're not as fond of ketamine as me, but I'm working on that. Or desflurane for that matter.

 

[BLADEMDA]

Until I get the email from the beancounters that IV acetaminophen costs too much for routine use, I'm going to keep using it.

My usual approach now (adults) is
1. Ketamine 0.5 mg/kg IV with induction (0.25 mg/kg for short or non-painful cases)
2. Dexamethasone 4 mg IV with induction
3. Ketorolac 30 mg with induction, or earlier if I have it drawn up already
4. Tylenol IV after the antibiotics

I do reduce the ketorolac dose for old people. I used to give fentanyl with induction to blunt laryngoscopy, now I use esmolol, and hold off on opiates as long as I can. Occasionally I get away with zero opiate, but usually I feel a need for some around wakeup. It's worlds better than what I used to do, which was occasional ketamine, no IV acetaminophen, early opiate, and ketorlac late in the case. I've always liked ketamine, but only recently did I start giving it to just about everyone.

Lately I've sometimes been adding 2-3 g of magnesium to the IV bag. I'm not sure how much good it's doing though.

Maybe in a couple years I'll be doing something totally different. 🙂

We agree here and I do use IV Tylenol more often than not because the CRNAs, RNS, etc love it. That said, I don't think it is worth $35 more than the $1.0 PO version when you add items 1-3 to the Tylenol. For those who don't have IV Tylenol on your formulary just go with the PO version and look at adding the other items to your non opioid analgesic regimen.

 

[BLADEMDA]

PGG,

I do think we are on to something here; if we utilize items 1-4 (IV or PO Tylenol) combined with some local by the surgeon or better yet, a block by an Anesthesiologist, we may be able to avoid opiods altogether. I haven't been using Mg++ much except for chronic pain patients where I add 2 grams to the IV fluids. I'm doubtful about the utility of Mg++ for the average outpatient.
That said, there are studies out there touting its effectiveness for reducing opioid use:

http://www.ncbi.nlm.nih.gov/pubmed/23121612


http://www.ncbi.nlm.nih.gov/pubmed/23669270

 

[BLADEMDA]

The use of Gabapentin or Lyrica can be helpful in reducing postop pain and the incidence of Neuralgia. For patients with pre-existing pain the use of Lyrica is especially helpful.

Here is a nice review from our favorite residency program on SDN:

http://www2.pitt.edu/~srna100/Clini...cle-Useful_adjuvants_for_post-op_pain_mgt.pdf

 

[Ignatius J]

That's a nice theory, but these discussions only tend to happen when surgeons are cranky about something, and however nice and professional you are, the cranky ones just aren't in a receptive mood. I guess you could bring up the subject in advance, but that seems wrong for another reason - why should we ask them permission to use anesthetic and analgesic drugs?

I'd rather not have a discussion at all, and let the wakeups do the talking re: the quality of my anesthetic. If a tree falls in the forest, and a patient does well, and the surgeons don't read the anesthetic record, does the preop ketorolac they don't know about make a sound? Note that I'm not advocating deceiving them. But I don't tell them how much propofol or fentanyl I give, either.


I have had one surgeon get irritated with my pre-emptive ketorolac. Late in an outpatient lap chole she gave me "permission" to give it. I acknowledged her words but didn't move, and I guess that non-movement tipped her off that I'd already given it. She asked, I said yes, and she got mad, and started lecturing about how it's her decision that she need to assess the gall bladder bed first, because bleeding.

Of course, she had also criticized my fluid management, and at one point felt the need to tell me that "rocuronium lasts one hour" ... I could refer her to that RCT meta-analysis but it's not like she'd read it.

These are exactly the sort of discussions I prefer not to have with exactly the sort of surgeons I prefer not to talk to. It's a non-issue with the rest.





Acetaminophen + ketorolac is better than ketorolac. 🙂

Ketamine + acetminophen + ketorolac is even better. 😀

If that's the case, just give it and don't say anything about it. Use the literature as the crux if they mention anything.

I've still never had a problem with surgeons getting pissed at giving toradol. Never even close. I'm sure they're out there, but just not a good or frequent enough reason to deny a patient a very good drug. Just give it, explain if needed.

 

[Planktonmd]

If that's the case, just give it and don't say anything about it. Use the literature as the crux if they mention anything.

I've still never had a problem with surgeons getting pissed at giving toradol. Never even close. I'm sure they're out there, but just not a good or frequent enough reason to deny a patient a very good drug. Just give it, explain if needed.

If the patient bleeds for any reason, including poor surgical technique, some surgeons will blame your Ketoralac.
I have seen it happen many times and it's not easy to defend, the surgeon can say that he did not want you to give NSAIDs, and that you gave it without consulting with him, Now guess who the hospital and the peer review committee will side with???
I am not saying don't give it but you need to make sure that the surgeon is OK with it.

 

[Ignatius J]

If the patient bleeds for any reason, including poor surgical technique, some surgeons will blame your Ketoralac.
I have seen it happen many times and it's not easy to defend, the surgeon can say that he did not want you to give NSAID
s, and that you gave it without consulting with him, Now guess who the hospital and the peer review committee will side with???
I am not saying don't give it but you need to make sure that the surgeon is OK with it.

I am well aware of the "what would you say in court?" type of argument.

Here is a stepwise cheat sheet on how to handle this dilemma. I have followed it and never found myself close to a peer review committee.

1.) Do what you think is best for the patient.
2.) If contested, discuss nice and professionally the relevant literature.
3.) if still contested, ask for any relevant literature on side of contestor.
4.) Consider stance.
5.) If you find yourself in front of a peer review committee, discuss relevant literature nicely and professionally. Discuss differences between a surgical bleed and coagulopathy.

Give Toradol to all patient who I feel need it. Never had a problem.

For pain management, I absolutely try and be considerate to all party concerns in patient care. That's within reason. Just like I am not going to not give Propofol because the surgeon claims it gave his last patient cooties. that is about as evidence-based as Toradol causing post-op bleeding (adult tonsils not withstanding).

 

[Planktonmd]

I am well aware of the "what would you say in court?" type of argument.

Here is a stepwise cheat sheet on how to handle this dilemma. I have followed it and never found myself close to a peer review committee.

1.) Do what you think is best for the patient.
2.) If contested, discuss nice and professionally the relevant literature.
3.) if still contested, ask for any relevant literature on side of contestor.
4.) Consider stance.
5.) If you find yourself in front of a peer review committee, discuss relevant literature nicely and professionally. Discuss differences between a surgical bleed and coagulopathy.

Give Toradol to all patient who I feel need it. Never had a problem.

Ok i hope this continues to work for you😉

 

[kazuma]

We a e in the same boat with the 3x cost I increase so they took it off our formulary. I wish we still had it even if reserve just for peds cases.

Now I just give adults PO if I remember to grab it/administer it and there's no contraindications.

I also am a big fan of multimodal analgesia and opioid sparing.

I try to use the following combo as much as possible.

I've been starting to give 900mg gabapentin with the usual 1g Tylenol in preop.

0.5mg/kg Ketamime at induction if the case is short (might start decreasing to 0,25mg/kg) or up to 1mg/kg for longer cases. Infusion for chronic pain pts or spines.

Up to 0.2mg/kg decadron.

50mg/kg Magnesium ran in over 10-20 min.

I find that with this combo I can get through a VATS with 150-250mcg Fentanyl without IT morphine or epidural.

I need to start using or advocating for ketorolac more, but I've had some similar concerns with surgeons fearing bleeding.

 

[Ignatius J]

We a e in the same boat with the 3x cost I increase so they took it off our formulary. I wish we still had it even if reserve just for peds cases.

Now I just give adults PO if I remember to grab it/administer it and there's no contraindications.

I also am a big fan of multimodal analgesia and opioid sparing.

I try to use the following combo as much as possible.

I've been starting to give 900mg gabapentin with the usual 1g Tylenol in preop.

0.5mg/kg Ketamime at induction if the case is short (might start decreasing to 0,25mg/kg) or up to 1mg/kg for longer cases. Infusion for chronic pain pts or spines.

Up to 0.2mg/kg decadron.

50mg/kg Magnesium ran in over 10-20 min.

I find that with this combo I can get through a VATS with 150-250mcg Fentanyl without IT morphine or epidural.

I need to start using or advocating for ketorolac more, but I've had some similar concerns with surgeons fearing bleeding.

You can give it to children PO as well. In ones being pre-medicated for anxiolysis, it apparently makes the versed taste more tolerable. Blade has given some literature on the subject- it seems IV versus PO doesn't make much difference.

Sorry to keep beating this drum, but I am passionate about this because I think using Ofirmev, especially in lieu of more effective adjuncts like Toradol, is a disservice to the patient. At risk of sounding to arrogant, blindly giving Ofirmev is a "cRNa move". I don't see much of a place for it.

 

[kazuma]

You can give it to children PO as well. In ones being pre-medicated for anxiolysis, it apparently makes the versed taste more tolerable. Blade has given some literature on the subject- it seems IV versus PO doesn't make much difference.

Sorry to keep beating this drum, but I am passionate about this because I think using Ofirmev, especially in lieu of more effective adjuncts like Toradol, is a disservice to the patient. At risk of sounding to arrogant, blindly giving Ofirmev is a "cRNa move". I don't see much of a place for it.

Yeah, I agree, we'll give it to kids PO as well, but I've had attendings that get nervous because they're worried about the total volume of the tylenol combined with versed.

Ofirmev is convenient to have, but I agree that it's not worth $36, even at $10 I thought it was questionable. In the end, the only thing preventing most patients from receiving Tylenol peri-op is our own laziness.

 

[epidural man]

I have a few points to add...

1. IV Tylenol absolutely works better than oral in more patients then we would like to admit. That is because of polymorphism in our cytochrome system. I don't remember the numbers exactly, but I think up to 1/3 of patients with 1gm of oral Tylenol will NOT get to a therapeutic level because of 1rst-pass metabolism. (So if you say tylenol doesn't work of you - it's probably true. Just know that it works great in others.) 100% of IV doses get to a therapeutic level.

2. Agree that ketoralac does not increase bleeding - lots of patients and doses to show this (in the literature) - except in tonsils where it has been shown to clearly increase post op bleeding. Don't use it in tonsils. As an interesting side note on Ketoralac... the oral, IM, and IV route all have the same bioavailability, onset and duration. I used to jam me in the muscle when I took a dose at work, now I just drink it - tastes horrible.

3. IV Tylenol probably doesn't have a huge effect - and you probably get the most bang for your buck by avoiding intraoperative opioids all together. However, it's probably worth $15.

 

[norwood]

Edit - I should qualify the above by saying that if I'm working with a resident, I generally let them do what they want, within reason. As a group they're not as fond of ketamine as me, but I'm working on that. Or desflurane for that matter.

What do the residents have against desflurane? Bronchospasm in asthmatics/smokers?

 

[pgg]

What do the residents have against desflurane? Bronchospasm in asthmatics/smokers?

I think they've been told too many times that
- it's a nurse's gas
- you can wake up anyone just as fast with isoflurane, if you don't suck
- it's deathflurane
Silly stuff, but when you're a resident you try to do cases the way you think your attending wants them done. I think some are reluctant to use it for fear of their attending-of-the-day thinking less of them. Yeah, it's dumb.