Ponv

[MAC10]

Advertisement - Members don't see this ad

Do you private practice guys usually give prophylaxis for every patient or just those considered high risk for PONV? I am especially curious what the concensus is for outpatinet surgery. What drugs/ methods (ie Zofran, multimodal, Nitrous?)do you perfer.

 

[militarymd]

Do you private practice guys usually give prophylaxis for every patient or just those considered high risk for PONV? I am especially curious what the concensus is for outpatinet surgery. What drugs/ methods (ie Zofran, multimodal, Nitrous?)do you perfer.

Surgery centers will treat everyone.

I personally try to treat only those at risk based on the scoring index. I have associates who treat everyone.

 

[Monty Python]

Do you private practice guys usually give prophylaxis for every patient or just those considered high risk for PONV? I am especially curious what the concensus is for outpatinet surgery. What drugs/ methods (ie Zofran, multimodal, Nitrous?)do you perfer.

Our group covers both a large hospital and an ambulatory surgery center.

High risk pts (including young, female, non-smoker, laparoscopic case, ear or eye case, previous hx of PONV) get 10 mg decadron pre op, and 0.1 mg kytril. We're discouraged from using zofran due to cost, unless the surgeon specifically requests it.

I personally don't use inapsine due to a friend's recounting of the horrible dysphoria it caused.

 

[MAC10]

Alot of attendings i work with advocate double dose Zofran (4mg up front/4mg at the end). It seems to work but im not sure if this is a cost effective practice in the real world.

 

[jetproppilot]

Alot of attendings i work with advocate double dose Zofran (4mg up front/4mg at the end). It seems to work but im not sure if this is a cost effective practice in the real world.

Zofran prophylaxis is ubiquitous...dont know whether its truly scientific or a result of their huge marketing...

 

[bullard]

In the editorial that accompanies the following abstract, Paul White notes that two cheaper antiemetics like dexamethasone and droperidol used in conjunction are more beneficial than one 5-HT3 antagonist, and that from a societal cost-benefit point of view, slamming everybody with Zofran is absurd. I'm gonna go with Dr. White on this one. 🙂

--------------
A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting

Christian C. Apfel, M.D., Kari Korttila, F.R.C.A., Ph.D., Mona Abdalla, Ph.D., Heinz Kerger, M.D., Alparslan Turan, M.D., Ina Vedder, M.D., Carmen Zernak, M.D., Klaus Danner, M.D., Ritva Jokela, M.D., Ph.D., Stuart J. Pocock, Ph.D., Stefan Trenkler, M.D., Markus Kredel, M.D., Andreas Biedler, M.D., Daniel I. Sessler, M.D., Norbert Roewer, M.D., for the IMPACT Investigators

ABSTRACT

Background Untreated, one third of patients who undergo surgery will have postoperative nausea and vomiting. Although many trials have been conducted, the relative benefits of prophylactic antiemetic interventions given alone or in combination remain unknown.

Methods We enrolled 5199 patients at high risk for postoperative nausea and vomiting in a randomized, controlled trial of factorial design that was powered to evaluate interactions among as many as three antiemetic interventions. Of these patients, 4123 were randomly assigned to 1 of 64 possible combinations of six prophylactic interventions: 4 mg of ondansetron or no ondansetron; 4 mg of dexamethasone or no dexamethasone; 1.25 mg of droperidol or no droperidol; propofol or a volatile anesthetic; nitrogen or nitrous oxide; and remifentanil or fentanyl. The remaining patients were randomly assigned with respect to the first four interventions. The primary outcome was nausea and vomiting within 24 hours after surgery, which was evaluated blindly.

Results Ondansetron, dexamethasone, and droperidol each reduced the risk of postoperative nausea and vomiting by about 26 percent. Propofol reduced the risk by 19 percent, and nitrogen by 12 percent; the risk reduction with both of these agents (i.e., total intravenous anesthesia) was thus similar to that observed with each of the antiemetics. All the interventions acted independently of one another and independently of the patients' baseline risk. Consequently, the relative risks associated with the combined interventions could be estimated by multiplying the relative risks associated with each intervention. Absolute risk reduction, though, was a critical function of patients' baseline risk.

Conclusions Because antiemetic interventions are similarly effective and act independently, the safest or least expensive should be used first. Prophylaxis is rarely warranted in low-risk patients, moderate-risk patients may benefit from a single intervention, and multiple interventions should be reserved for high-risk patients.

 

[VentdependenT]

Surgery centers will treat everyone.

I personally try to treat only those at risk based on the scoring index. I have associates who treat everyone.

mmd whats the scoring index?

I go by risk factors and history but don't assign a score.

Those at risk:
young women
gyn surgery
abd surgery
laproscopic procedures
high narcotics


Most folks will get 8mg of decadron because its cheap and its relatively benign.

Outpatients will get the zofran, reglan, and decadron.

I've also heard o the old scopolomine patch but have only used it once.

 

[jetproppilot]

mmd whats the scoring index?

I go by risk factors and history but don't assign a score.

Those at risk:
young women
gyn surgery
abd surgery
laproscopic procedures
high narcotics

.

and eyes

 

[jetproppilot]

and eyes

and people prone to motion sickness

alfentanil reportedly causes more nausea than fentanyl/sufentanyl/remifentanyl, but it isnt used that much.

 

[militarymd]

Alot of attendings i work with advocate double dose Zofran (4mg up front/4mg at the end). It seems to work but im not sure if this is a cost effective practice in the real world.

The second dose has been SHOWN not to be efficacious.

 

[mustangsally65]

Those at risk:
young women
gyn surgery
abd surgery
laproscopic procedures
high narcotics

I'm pre-med, so I have no background in this area. But I'm curious: why are young women more at risk?

 

[jetproppilot]

I'm gonna go with Dr. White on this one. 🙂

If I were a resident, and Dr White posts a paper saying something,

I'd abide by it.

Dude's an anesthesia advocate, a scientist, and a clinician.

Very few people in our business meet those three criteria.

Among the "savior" anesthesia-scientists,

Paul White is amongst the very-few, science-supported-anesthesia- clinicians.

Listen to his suggestions.

 

[bigdan]

Paul White is amongst the very-few, science-supported-anesthesia- clinicians.

Listen to his suggestions.

Jet and the group-

I went to our visiting professor lecture here at Stony Brook when Dr. White spoke. He covered a fairly broad array of topics regarding pharmacologic interventions, and every single point he made was supported by a paper (often his own - I'd love to know the number of paper's he's authored). That was impressive.

The other thing that stuck with me was his fairly firm stance against(read: absolute opposition to) use of Kytril, for what it's worth.

dc

 

[MAC10]

Results Ondansetron, dexamethasone, and droperidol each reduced the risk of postoperative nausea and vomiting by about 26 percent. Propofol reduced the risk by 19 percent, and nitrogen by 12 percent; the risk reduction with both of these agents (i.e., total intravenous anesthesia) was thus similar to that observed with each of the antiemetics. All the interventions acted independently of one another and independently of the patients' baseline risk. Consequently, the relative risks associated with the combined interventions could be estimated by multiplying the relative risks associated with each intervention. Absolute risk reduction, though, was a critical function of patients' baseline risk.

Interesting stuff. Does "nitrogen" here refer to nitrous oxide? Cause ive gotten the impression from my learning institution that nitrous oxide increases incidence of nausea and vomiting.

 

[joncmarkley]

trinityalumnus, 10 mg decadron. better hope no one gets septic post op because they will try to blame your steroids in court 🙁

 

[VentdependenT]

trinityalumnus, 10 mg decadron. better hope no one gets septic post op because they will try to blame your steroids in court 🙁

?

Have you read the "surviving sepsis campaign guidlines?"
Roids are supported for sepsis.

 

[bullard]

They really do mean nitrogen. Totally missed that. Weird, I've never seen it on an anesthesia machine (in 2 months of anesthesia as an MS4).

Interesting stuff. Does "nitrogen" here refer to nitrous oxide? Cause ive gotten the impression from my learning institution that nitrous oxide increases incidence of nausea and vomiting.

 

[VentdependenT]

Nitrogen is already >70% of the air we breath so I dont see what the hell people are doing with that on their machines. The "air" on board should suffice.

 

[Stillinscrubs]

I'm pre-med, so I have no background in this area. But I'm curious: why are young women more at risk?

From my limited reading of the lit. just bad luck. I haven't seen a mechanism or don't recall a mechanism mentioned.... Also never heard young women, just women mentioned. Understand it also could be skewed since men don't undergo much gyn. surgery (for obvious reasons.) If I have misspoken blast away.

A question. Also from limited reading of the lit. Do any of you take smoking history into your plan development?

Always enjoy the posts guys.

 

[jwk]

mmd whats the scoring index?

I go by risk factors and history but don't assign a score.

Those at risk:
young women
gyn surgery
abd surgery
laproscopic procedures
high narcotics


Most folks will get 8mg of decadron because its cheap and its relatively benign.

Outpatients will get the zofran, reglan, and decadron.

I've also heard o the old scopolomine patch but have only used it once.

All our patients get pepcid and reglan preop. Droperidol isn't available in our hospital, nor is anzemet or kytril. Most will get zofran, those with a history of PONV get a scop patch. We've had better luck with this regimen than any of the others except drop. We also have some plastic surgeons that are hung up on the double zofran-decadron-benadryl-no nitrous-scop patch regimen in addition to pepcid and reglan despite our concerns that it is gross overkill and a slight but real risk of AVN secondary to the steroids. Good pre-emptive pain control and early aggressive rehydration go a long way towards decreasing PONV as well.

 

[militarymd]

?

Have you read the "surviving sepsis campaign guidlines?"
Roids are supported for sepsis.

Vent, you beat me to it.

 

[Noyac]

Young women ( possibly do to menstrual cycle, likely)
Non-smokers are added to my criteria.

Not trying to start something here but I found that nurses give antiemetics to all comers (mostly Zofran and in double doses w/c is a waste) while physicians tend to use the criteria more often. No difference in PONV b/w the two but def finite difference in cost.

What are your opinions about Kytril? Our hosp. just dropped anzemet (crap anyway) in favor of Kytril. We still have zofran.

 

[rn29306]

High risk pts (including young, female, non-smoker, laparoscopic case, ear or eye case, previous hx of PONV) get 10 mg decadron pre op, and 0.1 mg kytril.

Ever had anyone get the dreaded "crotch burning / itching / intense discomfort" from decadron while in pre-op or at induction? Was witness to this recently and now my pts get this after he / she is asleep. Not knocking ya at all Trin, just wondering..

 

[VentdependenT]

I have witnessed that with decadron. So I'll give it after the versed or after the pt is asleep.

 

[Monty Python]

Ever had anyone get the dreaded "crotch burning / itching / intense discomfort" from decadron while in pre-op or at induction? Was witness to this recently and now my pts get this after he / she is asleep. Not knocking ya at all Trin, just wondering..

If it's a short case I'll slowwwwwwly push it after the versed is in. Usually as I'm wheeling down our blasted 100 yard long hallway from holding to the ORs.

For longer cases in a healthy pt (with no worries about CHF) I'll add the decadron to the first liter of IVF, which I'll run in rather fast. I've found keeping the pt properly hydrated goes a long way towards reducing PONV. In young healthy females with no worries of CHF, I'll having them peeing almost clear urine in PACU And anecdotally I've noted this slight over-hydration has helped reduce PONV.

 

[Monty Python]

.....Dr. White spoke......his fairly firm stance against(read: absolute opposition to) use of Kytril

Rationale?

And I also think anzimet is worthless.

 

[rn29306]

If it's a short case I'll slowwwwwwly push it after the versed is in. Usually as I'm wheeling down our blasted 100 yard long hallway from holding to the ORs.

For longer cases in a healthy pt (with no worries about CHF) I'll add the decadron to the first liter of IVF, which I'll run in rather fast. I've found keeping the pt properly hydrated goes a long way towards reducing PONV. In young healthy females with no worries of CHF, I'll having them peeing almost clear urine in PACU And anecdotally I've noted this slight over-hydration has helped reduce PONV.

One of my friends is doing his thesis on PONV. Hydration is a biggie in regards to PONV.

 

[Noyac]

Hydration is a biggie in regards to PONV.

Absolutely.
Probably the biggest determinant.

 

[bigdan]

Trinity-

Not so sure...I believe that a some of it is related to his belief of cost/cost effectiveness, but don't quote me. Ironically enough, I just read an abstract by him that found significant benefit of Kytril over ondansetron for nausea and emesis intervention after discharge from outpatient laproscopic surgery.

Maybe I remember wrong...

dc

 

[militarymd]

from my reading, all serotonin antagonists are equally efficacious....however, this is coming from a guy who thinks puking is not a big deal..

 

[undecided05]

couple of things bout the roids... no big increase in immune compromise till at least 2 weeks on board. Also think about how pulse steroids in sepsis differ from a single wimpy dose of dec.


Also doubt anyone has gotten AVN with 1 dose of juice.

I usually feel better after puking, but I doubt the ENT docs that just messed with the peeps ears really want all that increased pressure.

As for women and PONV, I think I remember hearing something about it being mostly with the gyn surgeries that places them at risk and that's probably 2/2 all the vagal stimuli.

 

[jetproppilot]

Also doubt anyone has gotten AVN with 1 dose of juice.
.

Sorry, catabolic steroids cant be called "juice".

The nickname is reserved for anabolics!

Nasser El Son Baty would have your head for that one.

 

[jetproppilot]

Rationale?

And I also think anzimet is worthless.

anecdotally, despite the literature, I agree, and so does every PACU nurse I've ever worked with.

 

[coccygodynia]

I haven't seen it mentioned yet, but the PACU nurses swear by this one - leaving a small alcohol pad right by the nose helps to decrease the nausea (and subsequent emesis) during the recovery phase. This is in addition to any antiemetic already given.

 

[Noyac]

I haven't seen it mentioned yet, but the PACU nurses swear by this one - leaving a small alcohol pad right by the nose helps to decrease the nausea (and subsequent emesis) during the recovery phase. This is in addition to any antiemetic already given.

Holy ****! I completely forgot about that one. That is a trick that I learned from a crna at my first gig out of residency. He would put an alcohol wipe under the nose of the c/s pts that were feeling nauseated. (By the way, what kind of word is nauseous? I hate that word. "I feel nauseous") Sorry had to rant.

About steroids and AVN. VERY VERY unlikely. Even in transplant pts that are on long term high dose steroids, the incidence of AVN is only 3-6%. I really doubt that you would have to worry about one dose in the OR.

 

[jetproppilot]

Holy ****! I completely forgot about that one. That is a trick that I learned from a crna at my first gig out of residency. He would put an alcohol wipe under the nose of the c/s pts that were feeling nauseated. (By the way, what kind of word is nauseous? I hate that word. "I feel nauseous") Sorry had to rant.

About steroids and AVN. VERY VERY unlikely. Even in transplant pts that are on long term high dose steroids, the incidence of AVN is only 3-6%. I really doubt that you would have to worry about one dose in the OR.

Man,

I was hyped about the alcohol wipey-inhaling stuff several years ago, and made all the PACU nurses try it...

Trin, ask Barbara, Ellen et al...made them try it and they werent impressed. I was bummed.

 

[ThinkFast007]

from my reading, all serotonin antagonists are equally efficacious....however, this is coming from a guy who thinks puking is not a big deal..

This is what I heard from several attendings where I rotated through.