Ofirmev post c-section

[lane]

A couple of the newer OBs at my hospital have started ordering Ofirmev q6 x4 for their sections. It seems they got the idea after a nice drug rep dinner that recommended the regimen.

Is anyone else doing this for their post op pain? I balked initially because it's right at the FDA recommended 4g (or above it if you follow the recent 3g) and because it prevents using lortab or percocet once you're at that threshold. It also doesn't seem cost effective to use an IV drug for $13/bottle when PO pills are pennies each in a patient that has no problem taking PO.

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[Mman]

the little secret the Ofirmev reps won't tell them is that their drug is no more efficacious than dirt cheap oral acetaminophen. They like to talk about higher plasma levels and no first pass hepatic metabolism and on and on and on, but if you ask they admit that there are no studies comparing PO to IV and they don't like to admit that plasma level of acetaminophen doesn't correlate 1:1 with efficacy. It isn't a narcotic where giving more at once leads to better analgesia.

It has it's place in the world, but for patients that are taking PO, just give them the dirt cheap oral acetaminophen

 

[Libertas]

Regardless of large bodies of evidence it seems to work....many of our patients on the standing dose of iv seem to get much less narcotics post op. Some of our surgical services have become big believers. 10$/dose is still super cheap in the scheme of things.

And I believe 3G/ day is for outpatients....4g for inpatients?

 

[jwk]

Our PACU nurses swear by it, and we can definitely see a decrease in intra-op narcotic use for those patients getting IV Ofirmev - not so with PO acetaminophen given in pre-op.

However - if a patient isn't NPO, giving the Ofirmev is overkill. It's cheaper to give PO as far as hospital costs - but don't assume they're charging the patient less. I know on my latest hospital bill, Ofirmev = dilaudid = fentanyl as far as what is charged to the patient at our hospital..

 

[pgg]

That's silly and wasteful.

I use it frequently intraop. Most non-trivial cases I do these days, after the antibiotic has dripped in, I'll put 1g of acetaminophen through the same piggyback tubing. I'm a believer that $10 or $14 or whatever is well spent on IV acetaminophen at that point. I'm not motivated enough to give it PR, even though that's a far cheaper and probably an equally effective way to give it.

 

[pjl]

I use it for pain after C/S only when the usual options have failed. Based on my personal experience it is substantially more effective than oral tylenol, although this is likely more due to speed of onset than peak effect. It is very frequently used for "regular" outpatient procedures here as well. 30 min earlier comfort = 20 min earlier PACU discharge in many cases, and that helps the throughput.

 

[Bostonredsox]

most all of our CABG patients get 4 doses of it post op. Not sure if its any more efficacious for pain control but Its a hell of a lot easier on the nurses then rectal Tylenol, as most of my patients can take anything PO. I am seeing a lot of post op q6h x4 dose IV Tylenol + IV toradol. Don't have any data to support it but I feel like we are giving less fentanyl and dilaudid to the patients getting this regimen.

 

[Oggg]

Our c section pts get lots of ketorolac postop when the duramorph (or TAPs) wear off. Are you giving ofirmev on top of ketorolac?

 

[Bostonredsox]

Our c section pts get lots of ketorolac postop when the duramorph (or TAPs) wear off. Are you giving ofirmev on top of ketorolac?

I don't give either, the surgeons do. Im usually just managing the vent for them postop. But I have noticed they are giving both postop for 14 hours quite frequently.

 

[kazuma]

Our c section pts get lots of ketorolac postop when the duramorph (or TAPs) wear off. Are you giving ofirmev on top of ketorolac?

If the patient doesn't have a contraindication to either and I'm trying to spare narcotics, then yes, I give both. I use ofirmev alone frequently as well. I agree that PACU nurses swear by it and I receive feedback from them that my patients seem to be very comfortable postop with less narcotics than other residents/CRNA's. "Oh you gave IV Tylenol? Thank you!" FWIW.

 

[urge]

I have a hard time believing that Ofirmev works . PO Tylenol doesn't do anything for me. I wouldn't expect any different for the iv version.

But, yes, a lot of people swear by it in my hospital. I estimate that it is used in >90% of our cases.

 

[G0S2]

I have a hard time believing that Ofirmev works . PO Tylenol doesn't do anything for me. I wouldn't expect any different for the iv version.

But, yes, a lot of people swear by it in my hospital. I estimate that it is used in >90% of our cases.

Data shows higher CSF concentration explaining possible "central" effect.

 

[urge]

nevermind

 

[kazuma]

Tylenol PO works very well for me personally in terms of headaches, and knee pain relief in the 250-500mg/day dosage. But even better when combined with asa250mg and caffeine65mg in the form of excedrine.

 

[BLADEMDA]

I have a hard time believing that Ofirmev works . PO Tylenol doesn't do anything for me. I wouldn't expect any different for the iv version.

But, yes, a lot of people swear by it in my hospital. I estimate that it is used in >90% of our cases.

I use a ton of that crap at my hospital. I'd say 50-100 bottles a week easily. CRNAs and Nurses love it. I think it's all marketing hype and despite the drug reps data showing me efficacy I remain unconvinced.

What I am convinced about are long acting blocks with BUP plus Decadron or EXPAREL.
It's amazing how many of us will use a $2.00 tuohy needle but happily give a $25 bottle of IV Tylenol (instead of a 10 cent Tablet PO). It's all marketing hype but I readily admit the sales pitch is working.

 

[BLADEMDA]

http://www.anesthesiologynews.com/download/sr122_wm.pdf

The data is mostly all here. CSF concentration is higher with IV Tylenol vs PO Tylenol.

 

[BLADEMDA]

 

[BLADEMDA]

So, I give the IV Tylenol intraop because it may help some and operations are expensive. That said, once patients are tolerating PO meds or after 4 doses of IV Tylenol ($100) hospitals should switch patients to PO Tylenol.

Instead of spending $100 on Tylenol spend $280 on EXPAREL and place a nerve block. IMHO, that's much better use of limited health care dollars. By the way, I do NOT own stock in the company producing Exparel (Doze has talked me out of buying individual stocks).

 

[BLADEMDA]

 

[Oggg]

By the way, I do NOT own stock in the company producing Exparel (Doze has talked me out of buying individual stocks).

Whahhhhhhhtttt?! It's gambling but it's fun and exciting to buy stuff (with a limited portion of your portfolio).

 

[Southpaw]

I've seen the data, but am unsure that a higher CSF concentration really means anything other than simply higher CSF concentration. It may be fair to make the jump and say that translates into better, faster pain control, or better, faster inflammatory mediator inhibition, but there are no studies showing that. And since Ofirmev is making boatload after boatload of cash by simply showing a higher CSF concentration, I highly doubt they're interested in looking for the answers that I want.

I practice in an area where I really do need to practice cost conscious medicine. It's very different from residency where we just did whatever we wanted, and never considered cost. I've used IV Tylenol at times, but think more and more that if I really want to use it I'll just give some PO Tylenol at the beginning of the case.

All this being said, what really matters is what the surgeons think since they manage the patient's pain much longer than we do. And my impression is that just about all of them have bought into the belief of IV Tylenol, likely because bedside RNs tell them how great it is. So maybe there is something to it, but honestly I'm not seeing it.

 

[jwk]

Instead of spending $100 on Tylenol spend $280 on EXPAREL and place a nerve block. IMHO, that's much better use of limited health care dollars. By the way, I do NOT own stock in the company producing Exparel (Doze has talked me out of buying individual stocks).

One catch - cost of administering $100 of IV Tylenol - $0.

Cost of administering $280 dose of Exparel - double or triple the cost of the drug to perform the block.

 

[sleepallday]

It's all about a multi-modal approach. This includes the nerve block, narcotics, nsaids, and tylenol. Gots to block all the pain transmission signals.

I'm not sure who is giving adults rectal tylenol. I never have. The better option is the IV form for patients that can't take PO. However, one concern is educating the patients on how much norco or tylenol they can take once they leave.

 

[Mman]

IV Paracetamol has been available for a long time in the UK and it hasn't displaced po acetaminophen.

It's nice in patients that can't take PO, but there is plenty of evidence that IV acetaminophen does not provide more pain relief than PO acetaminophen. Higher plasma levels, higher CSF levels, etc. Unfortunately those don't correlate with pain control.

 

[BLADEMDA]

IV Paracetamol has been available for a long time in the UK and it hasn't displaced po acetaminophen.

It's nice in patients that can't take PO, but there is plenty of evidence that IV acetaminophen does not provide more pain relief than PO acetaminophen. Higher plasma levels, higher CSF levels, etc. Unfortunately those don't correlate with pain control.

But it does correlate with higher profits and thus, lots of marketing hype.

 

[BLADEMDA]

One catch - cost of administering $100 of IV Tylenol - $0.

Cost of administering $280 dose of Exparel - double or triple the cost of the drug to perform the block.

Exparel works. If I had an operation I would want Exparel with Decadron or Bup with Decadron. I'd prefer the Exparel most of the time.

 

[fakin' the funk]

But it does correlate with higher profits and thus, lots of marketing hype.

😱😱😱

 

[deleted162650]

There's an article outta Lma Loinda Children's in the 9/13 issue of anesthesiology news which looked at IV v PO acetaminophen in kids s/p cleft palate repair. They were found to be equally effective and opioid sparing.

 

[Mman]

There's an article outta Lma Loinda Children's in the 9/13 issue of anesthesiology news which looked at IV v PO acetaminophen in kids s/p cleft palate repair. They were found to be equally effective and opioid sparing.

shocking I know.

They are both good drugs. One is just a lot cheaper than the other.