IV Tylenol

[gotname]

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Do you use IV Tylenol frequently or more so narcotics or NSAIDs in your anaesthestic regimen?

I just had my 1st experience with IV Tylenol (with 100mcg fentanyl, 12.5mg phenergan, some medrol as well as the "gas") and surprisingly, this was the smoothest post-op ever. No n/v and pain was tolerable enough the 1st two days so never filled the pain med prescription.

***I am comparing this to the other operations (+10) where opiates and/or NSAIDs were used and I always have n/v afterwards (even with phenergan). Admittedly, the post-op pain is hard to give a true comparison as it is not as black and white as n/v.

Anyway, got me wondering if it's just me giving credit to tylenol or it is actually quite helpful and is just not used much in anaesthesiology?

Appreciate your thoughts.

 

[IkeBoy18]

they dont like it at my place because its so expensive and since there are so many other options. Unless there is a specific reason youre limited to tylenol in a pt, the bean counters dont like to see it.

 

[Twiggidy]

I'm not the greatest at quoting studies, but I do believe it reduced opioid requirements in PACU when given prior to incision. We use it almost all the time we'd rather spend the money and give less narcs and potential complications of narcs. Again, I'm not quoting studies because I'm too lady to look them up.

 

[Shouldawouldacouldas]

Our bean counters do not approve of IV APAP. I wish I had it available.

 

[pgg]

Last I looked, our cost was a whole $6.33 per bottle. We use tons of it.

 

[Planktonmd]

Yes the price came down significantly, and despite all the skepticism out there I think it provides good post-op analgesia and opiate sparing, far superior to PO Acetaminophen, since it does not have to go through the liver first ( no first pass effect) which means the whole 1000 mg is fully available immediately.

 

[caligas]

I use it to treat PACU nurses. Gives me one more answer (in addition to other appropriate things) when they call.

 

[gotname]

Thanks!

For those that use it a lot or would like to, do you get any hesitation from patients? We live in a time where narcotics are automatically the go-to for pain so can something like IV Tylenol (or another safe substitute) easily become commonplace even used with minimal opiates or it would be a rough transition because of the mindset that norco/percocet etc. are the ones that work?

they dont like it at my place because its so expensive and since there are so many other options. Unless there is a specific reason youre limited to tylenol in a pt, the bean counters dont like to see it.

Our bean counters do not approve of IV APAP. I wish I had it available.

Does the process not end up being a vicious cycle? Use opiate then likely anti-emetic to counter the opiate induced nausea and so forth. If there are meds that can prevent the piggy-back medication process, why not do that?

I occasionally forget that like everything else, healthcare is a business.

 

[Velefunt]

Use is very patient and surgery location specific as to the following:

At the ASC, peds who don't receive rectal tylenol may get IV tylenol depending on procedure - facilitates smooth wakeup and efficient turnover/discharge. However, also at the ASC, the RN's typically don't like us to give IV tylenol to adult,s because this prevents them from administering a first oral dose of narcotic/tylenol prior to discharge.

At the hospital, cost has tripled per vial, so use interestingly is more sparing. Typically, tend to use it in individuals who require a multi-modal analgesic regimen due to multiple narcotic "allergies," ineligibility to receive regional/neuraxial techniques with significant surgical incisions and patients where respiratory depression from narcotics/hypercapnia-prone (i.e.: bariatrics/obstructive sleep apnea) patients could benefit from less narcotic use.

 

[Impromptu]

The IV formulation was taken off of our formulary because prices doubled, then doubled again. I have since begun giving acetaminophen 1000 mg PO to many of the gyn patients pre-op. Anecdotally I see that the D&C's don't routinely need anything else post op. We do enough of them that I might consider a small study.

I love giving small doses of IV methadone to chronic pain patients coming in for inpatient back surgery. 5, 10, 15, or 20 mg depending on size and chronicity of narcotic use. You know who else loves it? The PACU nurses.

 

[sluggs]

Taking a longer look to include complicated abdominal cases, IV tylenol is cheaper than one opiate-induced ileum

 

[pgg]

Methadone is a great drug for all kinds of surgeries in chronic heavy opiate users. I wish we could get our pharmacy to stock it in the ORs. As it is, any time we want to use it, we have to go to the inpatient pharmacy window and pick it up, after putting an electronic order in the EMR.

 

[deleted9493]

Seems to reduce PONV if given early enough

http://www.sciencedirect.com/science/article/pii/S0304395913000092

 

[gotname]

At the hospital, cost has tripled per vial, so use interestingly is more sparing. Typically, tend to use it in individuals who require a multi-modal analgesic regimen due to multiple narcotic "allergies," ineligibility to receive regional/neuraxial techniques with significant surgical incisions and patients where respiratory depression from narcotics/hypercapnia-prone (i.e.: bariatrics/obstructive sleep apnea) patients could benefit from less narcotic use.

I would assume those with narcotic "allergies" (according to what I have read/heard) are out for something stronger? Is said approach used basically as a "you say you are allergic so we are not taking any chances" thing?

Seems like the use of "normal" & somewhat atypical regimens are dependent not only on the anaesthesiologist & patient but a lot on the administrators.

Seems to reduce PONV if given early enough

http://www.sciencedirect.com/science/article/pii/S0304395913000092

Interesting read. For now, I am inclined to believe this. I have never felt so great (n/v) post-op. Will see if it really is the tylenol after next procedure.

 

[GasEmDee]

I give IV acetaminophen and toradol whenever there are no contraindications.

 

[Random Anesthesiologist]

We used it a ton where I did my surg intern year. Here pharmacy banned it because of cost. If I could show reduction in hospital days, that would blow the cost argument out of the water. It's a great drug.

 

[mostwanted]

I have used it a number of times and still do, but from my experience it is not as effective as any of the opioids

 

[pjl]

The benefit vs cost was enough of an argument between pharmacy and us that we are currently underway in a very poorly done study, looking at a number of variables postoperatively comparing oral tylenol 1 hr preop to IV tylenol intaop.
Gotta love residents absolutely ignoring all critiques of study design because they need results sooner...

 

[Phyrst]

Not available in our hospital due to cost vs PO tylenol...most patients get preop oral tylenol though.

 

[gotname]

Not available in our hospital due to cost vs PO tylenol.

I saw cost comparison of the two

most patients get preop oral tylenol though.

Do correct me if I am misinformed but isn't the selling point of IV form (besides obvious quick onset) the fact that the metabolic process differs from oral form and it is "better distributed" (higher plasma levels)?

If true, then there may be a slight difference in giving po v. IV pre-op or no?

 

[pjl]

I saw cost comparison of the two



Do correct me if I am misinformed but isn't the selling point of IV form (besides obvious quick onset) the fact that the metabolic process differs from oral form and it is "better distributed" (higher plasma levels)?

If true, then there may be a slight difference in giving po v. IV pre-op or no?

That is the theory. I have not seen a study looking at any differences directly comparing the two. Maybe Blade or someone else has seen a head to head comparison.
Subjectively, IV seems to be better.

 

[agammaglobulin]

This study compares plasma levels achieved between IV and PO APAP and necessary levels to cause effective analgesia. 28% of subjects receiving PO (1300mg) compared with 100% of subjects receiving IV met this level. While peri-op PO dosing is often used, absorption may not be as good due primarily to delayed gastric emptying.

 

[pjl]

Yes, per the Cadence funded article it should be better, the question is if it is better in the "real world," and if so, if it is better enough to be worth the money. Either way, I like it, and it subjectively seems better.

 

[gotname]

@pjl thank you. Btw is Blade the Yoda of the Anaesthesiology forum?

 

[deleted162650]

Blade is the Yoda of data mining the Anesthesia literature base and finding then cut/pasting 8 articles from the Uzbekistan Journal of Anesthesia which support his opinion. 😀