Routine Lap Chole?

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BLADEMDA

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A 55 year mildly obese female presents for a Lap. Cholecystectomy.
Her PMH is significant for DM (IDDM), HTN, GERD (controlled on meds) and possible difficult intubation previously for appy. Also, she states anesthesia makes her "throw up for days".

PSH:

Open Appendectomy at age 20 under GA

Meds:

Insulin
Lisinopril
Protonix
Zantac

Labs:

Glucose (fingerstick) 180. other labs WNL EKG;WNL


Wt= 100Kg Ht: 5'7"

What is your plan here?

The SRNA wants to use an LMA. Opinions? Pre-op meds? Any further studies?

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Board answer,

preop: would ask about exercise tolerance, symptoms of autonomic dysfunction (early satiety, resting tachycardia, etc). Comprehensive airway examination including MP, TM, neck/jaw mobility. Check VS. premed: consider antacid of choice (bicitra, famotidine) +/- metoclopramide +/- midazolam as needed per H/P

intraop: have difficult airway equipment ready, consider awake FBO or topicalization with awake look. regular induction/DL if reassuring. (Realistically, if she doesnt look like she will be a difficult mask, I'll induce her, take a look, and use an LMA/bougie/backup of choice as neccesary. If she looks like a difficult mask as well she may buy herself an awake FBO. If I FBO, I'll take a DL after induction to see what the view is for future reference. ) I would check BS intraop q 1-2 hours depending on her H/P of glucose control poss A1C level if available (if not I wouldnt insist on getting one) and administer insulin as needed to keep BS 120-180.

An LMA for the whole case? Too many strikes against her to do it. You can do laparoscopic surgeries with LMAs but with her obesity, DM, GERD this isnt the patient to try it on.

As far as the PONV. It sounds severe but who knows what she got 35 years ago. I would probably proceed as normal with a balanced anesthetic (narcotic, inhaled agent, relaxant). I would administer antiemetic x 3. (drop, ondanestron, decadron even though shes diabetic). If you are truly worried you could do a propofol based anesthetic with a good local by the surgeon and use minimal narcotics. Ketorolac could be used for additional analgesia as long as her kidneys are ok (labs were supposedly normal)

postop: control pain and blood sugars
 
Assuming she is optimized and ready for surgery. Hopefully she didn't take her lisinopril this AM.

For the airway, as long as there was nothing too obvious on exam, I would induce and try direct laryngoscopy with a lightwand, intubating LMA, and fiberoptic nearby and ready to be employed.

ETT for the case, no LMA in this patient with risk factors and the need for abdominal insufflation.

Routine maintenance with volatile agent of choice avoiding N2O. Modest narcotics supplemented with ketorolac if no contraindications exist. Local by surgeon at port sites.

For the nausea, preop placement of scopolamine transdermal 1.5 mg. Ondansetron 4 mg intraoperatively. Would probably give a bit of decadron (with the caveat that it might boost her blood sugar a bit-if it helps prevent an unexpected admission for PONV, it is a fair trade-off). Haloperidol 0.5 mg or phenergan 6-12 mg for PACU rescue meds if needed.
 
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I agree if the airway looks reasonable then induce and have a look if not then it's an awake FO no way she's getting an LMA.
Propofol based anesthetic decadron early drop + odansetron at the end.
Continue regular meds adapt insuline to blood glucose.
 
Board answer,

preop: would ask about exercise tolerance, symptoms of autonomic dysfunction (early satiety, resting tachycardia, etc). Comprehensive airway examination including MP, TM, neck/jaw mobility. Check VS. premed: consider antacid of choice (bicitra, famotidine) +/- metoclopramide +/- midazolam as needed per H/P

intraop: have difficult airway equipment ready, consider awake FBO or topicalization with awake look. regular induction/DL if reassuring. (Realistically, if she doesnt look like she will be a difficult mask, I'll induce her, take a look, and use an LMA/bougie/backup of choice as neccesary. If she looks like a difficult mask as well she may buy herself an awake FBO. If I FBO, I'll take a DL after induction to see what the view is for future reference. ) I would check BS intraop q 1-2 hours depending on her H/P of glucose control poss A1C level if available (if not I wouldnt insist on getting one) and administer insulin as needed to keep BS 120-180.

An LMA for the whole case? Too many strikes against her to do it. You can do laparoscopic surgeries with LMAs but with her obesity, DM, GERD this isnt the patient to try it on.

As far as the PONV. It sounds severe but who knows what she got 35 years ago. I would probably proceed as normal with a balanced anesthetic (narcotic, inhaled agent, relaxant). I would administer antiemetic x 3. (drop, ondanestron, decadron even though shes diabetic). If you are truly worried you could do a propofol based anesthetic with a good local by the surgeon and use minimal narcotics. Ketorolac could be used for additional analgesia as long as her kidneys are ok (labs were supposedly normal)

postop: control pain and blood sugars

Great Answer. You Pass.

Now, can we slow it down for the newbies? Take it one step at a time?

For example, Preop Evaluation:

Patient not SOB and can walk up two flights of stairs. NO history of smoking or angina (FWIW) . NO problems with dizziness, normal HR at rest, no problems eating :D or with satiety. IN short no evidence of any autonomic dysfunction.

Still, what is the likelihood she has at least some CAD? What about diastolic dsyfunction? Is mild diastolic dysfunction likely here?

Further exam reveals a fat neck, normal thyromental distance and a Mallampati Class 2 airway (FWIW). She also adds they got the tube in on the fourth try with "their best guy."
 
Last edited:
SRNA claims that the "MDAs" over at the outpatient center use a fancy LMA for these patients routinely.

Anyone care to opine? Any Cowboys willing to use a "fancy" LMA on this patient (all the premeds you want in holding will be given).
 
Assuming she is optimized and ready for surgery. Hopefully she didn't take her lisinopril this AM.

For the airway, as long as there was nothing too obvious on exam, I would induce and try direct laryngoscopy with a lightwand, intubating LMA, and fiberoptic nearby and ready to be employed.

ETT for the case, no LMA in this patient with risk factors and the need for abdominal insufflation.

Routine maintenance with volatile agent of choice avoiding N2O. Modest narcotics supplemented with ketorolac if no contraindications exist. Local by surgeon at port sites.

For the nausea, preop placement of scopolamine transdermal 1.5 mg. Ondansetron 4 mg intraoperatively. Would probably give a bit of decadron (with the caveat that it might boost her blood sugar a bit-if it helps prevent an unexpected admission for PONV, it is a fair trade-off). Haloperidol 0.5 mg or phenergan 6-12 mg for PACU rescue meds if needed.

A. I like the Scopolamine patch idea. SRNA asks how much more effective the patch is vs.
EMEND ® (aprepitant) and routine anti-emetic meds.


B. SRNA asks how much decadron will you give this fat diabetic patient. Will it elevate her blood glucose and if so, for how long? Will Decadron elevate the blood glucose of non-diabetics?

C. SRNA asks if Reglan is an effective ant-emetic. If so, at what dose?

D. SRNA asks if intraop Droperidol is a safe and effective anti-emetic compared to Odansetron. Would you give both? If so, when would you give them?

E. SRNA asks how much Ketorolac you will give this patient with normal renal function. Does the dosage change for I.M. vs I.V.? Does the dosage change if the Ketorolac will be continued postoperatively by the surgeon for the next 24 hours?
 
So, if the patient took her Lisinopril this morning would you cancel the case?

If the patient is a poorly controlled diabetic with a blood sugar of 240 would you cancel the case? Would you give her Decadron? How much?
 
Br J Anaesth. 2002 Jun;88(6):824-7. Links

ProSeal versus the Classic laryngeal mask airway for positive pressure ventilation during laparoscopic cholecystectomy.

Lu PP, Brimacombe J, Yang C, Shyr M.
Department of Anesthesia, Chang Gung Memorial Hospital, 5 Fu-Hsin Street, Kuei-Shan Hsiang, 333 Taoyuan Hsien, Taiwan.
BACKGROUND: We tested the hypothesis that the ProSeal laryngeal mask airway (PLMA) is a more effective ventilatory device than the Classic laryngeal mask airway (LMA) for laparoscopic cholecystectomy. METHODS: Eighty anaesthetized, paralyzed patients (ASA 1-2, aged 18-80 yr) were randomly allocated for airway management with the PLMA or LMA. Ease of insertion and efficacy of seal were determined. Peak airway pressures were recorded immediately before and after carboperitoneum to 2.0 kPa. The inspired oxygen concentration and/or the ventilatory variable were adjusted according to a protocol to maintain SpO2 > or = 95% and E'CO2 < 6.0 kPa. Oxygenation was considered suboptimal if SpO2 fell to 94-90% and failed if SpO2 was < 90%. Ventilation was considered suboptimal if E'CO2 was > 6.0-7.3 kPa and failed if E'CO2 was > 7.3 kPa. RESULTS: First-time insertion success rates were higher for the LMA (40/40 vs 33/40; P = 0.02). Seven patients required two attempts with the PLMA. Oropharyngeal leak pressure was higher for the PLMA [29 (SD 6) vs 19 (4) cm H2O; P < 0.001]. There was a similar, significant increase in peak airway pressure after carboperitoneum for both devices (P < 0.001). Before carboperitoneum, oxygenation and ventilation were optimal in all patients in both groups. After carboperitoneum, oxygenation was optimal in all patients in both groups, but ventilation was suboptimal more frequently with the LMA (8 vs 0; P = 0.01). In three of these eight patients, ventilation failed but was subsequently optimal with the PLMA. CONCLUSION: The PLMA is a more effective ventilatory device for laparoscopic cholecystectomy than the LMA. We do not recommend the use of the LMA for laparoscopic cholecystectomy.
 
Anyone care to opine? Any Cowboys willing to use a "fancy" LMA on this patient (all the premeds you want in holding will be given).

Pro-Seal has been used "safely" per author (Brimacombe mainly) of studies in laparoscopic cases. If you can get a NG tube down and aspirate gastric content then it's probably ok.

B. SRNA asks how much decadron will you give this fat diabetic patient. Will it elevate her blood glucose and if so, for how long? Will Decadron elevate the blood glucose of non-diabetics?

C. SRNA asks if Reglan is an effective ant-emetic. If so, at what dose?

D. SRNA asks if intraop Droperidol is a safe and effective anti-emetic compared to Odansetron. Would you give both? If so, when would you give them?

E. SRNA asks how much Ketorolac you will give this patient with normal renal function. Does the dosage change for I.M. vs I.V.? Does the dosage change if the Ketorolac will be continued postoperatively by the surgeon for the next 24 hours?

B. 5mg it may elevate her blood sugar probably for 6-8h it can elevated bg of non-diabetics
C. Not in a peri-op setting
D. Yes and yes at the end of the case
E. 30mg bolus then 10mg/8h if i remember correctly haven't used it in more than a year.

So, if the patient took her Lisinopril this morning would you cancel the case?

If the patient is a poorly controlled diabetic with a blood sugar of 240 would you cancel the case? Would you give her Decadron? How much?
Today 09:43 PM

Would certainly not cancel in either setting, would still give decadron as benefit outweighs side effects 5mg. Patient complains of puking not having a high BG...
 
Surgeon request 60mg I.V. bolus of ketorolac at the end of the case.
SRNA looks puzzled and calls you. Surgeon says just ONE Dose and the drug won't be given again. What do you tell the SRNA? Would you give this dosage I.V.? What about I.M.?
 
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Surgeon request 60mg I.V. bolus of ketorolac at the end of the case.
SRNA looks puzzled and calls you. Surgeon says just ONE Dose and the drug won't be given again. What do you tell the SRNA? Would you give this dosage I.V.? What about I.M.?

Above 40 m.g. no increase in action, just increased adverse side effects. What's renal function, anyway? Give 30mg IV/60 mg I.M. I'd also have her double her protonix dose for the next day or two.

This lady would get a tube, bg checked, decadron 8, zofran 8, scop patch, (never used aprepitant, nor seen it in clinical settings), ketorolac for the road, plenty of local, and glidescope in room, minimal opiods intra-op.

Took ACE? No problem. BG 240? No problem. Might decrease the decadron dose. Give some regular ins. Agree with the preop assessments of CV status etc.
 
Ketorolac Injection - Clinical Pharmacology

Pharmacodynamics

Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug (NSAID) that exhibits analgesic activity in animal models. The mechanism of action of ketorolac, like that of other NSAIDs, is not completely understood but may be related to prostaglandin synthetase inhibition. The biological activity of ketorolac tromethamine is associated with the S-form. Ketorolac tromethamine possesses no sedative or anxiolytic properties.
The peak analgesic effect of ketorolac tromethamine occurs within 2 to 3 hours and is not statistically significantly different over the recommended dosage range of ketorolac tromethamine. The greatest difference between large and small doses of ketorolac tromethamine is in the duration of analgesia.
Pharmacokinetics

Ketorolac tromethamine is a racemic mixture of [-]S and [+]R-enantiomeric forms, with the S-form having analgesic activity.
Comparison of IV, IM and Oral Pharmacokinetics: The pharmacokinetics of ketorolac tromethamine, following IV, IM and oral doses of ketorolac tromethamine are compared in Table 1. In adults, the extent of bioavailability following administration of the ORAL and IM forms of ketorolac tromethamine was equal to that following an IV bolus.
Table 1
Table of Approximate Average Pharmacokinetic Parameters (Mean ± SD)Following Oral, Intramuscular and Intravenous Doses of Ketorolac Tromethamine
Pharmacokinetic
Parameters (units)
Oral*Intramuscular†Intravenous Bolus‡ 10 mg15 mg30 mg60 mg15 mg30 mgBioavailability (extent)100%Tmax1 (min)
44±3433±21§44±2933±21§1.1±0.7§2.9±1.8Cmax2 (mcg/mL)
[single-dose]
0.87±0.221.14±0.32§2.42±0.684.55±1.27§2.47±0.51§4.65±0.96Cmax(mcg/mL)
[steady state qid]
1.05±0.26§1.56±0.44§3.11±0.87§N/A||3.09±1.17§6.85±2.61Cmin3 (mcg/mL)
[steady state qid]
0.29±0.07§0.47±0.13§0.93±0.26§N/A0.61±0.21§1.04±0.35Cavg4 (mcg/mL)
[steady state qid]
0.59±0.20§0.94±0.29§1.88±0.59§N/A1.09±0.30§2.17±0.59Vß5 (L/kg)0.175±0.0390.210±0.044
% Dose metabolized = <50 %
Dose excreted in feces = 6
1Time-to-peak plasma concentration
% Dose excreted in urine = 91
% Plasma protein binding = 99
2 Peak plasma concentration
*Derived from PO pharmacokinetic studies in77 normal fasted volunteers
3Trough plasma concentration
†Derived from IM pharmacokinetic studies in 54 normal volunteers
4Average plasma concentration
‡Derived from IV pharmacokinetic studies in 24 normal volunteers
5Volume of distribution
§Mean value was simulated from observed plasma concentration data and standard deviation was simulated from percent coefficient of variation for observed Cmax and Tmax data
||Not applicable because 60 mg is only recommended as a single dose
Linear Kinetics: In adults, following administration of single ORAL, IM or IV doses of ketorolac tromethamine in the recommended dosage ranges, the clearance of the racemate does not change. This implies that the pharmacokinetics of ketorolac tromethamine in adults, following single or multiple IM, IV or recommended oral doses of ketorolac tromethamine, are linear. At the higher recommended doses, there is a proportional increase in the concentrations of free and bound racemate.
Distribution: The mean apparent volume (V&#946;) of ketorolac tromethamine following complete distribution was approximately 13 liters. This parameter was determined from single-dose data. The ketorolac tromethamine racemate has been shown to be highly protein bound (99%). Nevertheless, plasma concentrations as high as 10 mcg/mL will only occupy approximately 5% of the albumin binding sites. Thus, the unbound fraction for each enantiomer will be constant over the therapeutic range. A decrease in serum albumin, however, will result in increased free drug concentrations.
Ketorolac tromethamine is excreted in human milk (see PRECAUTIONS: Nursing mothers).
Metabolism: Ketorolac tromethamine is largely metabolized in the liver. The metabolic products are hydroxylated and conjugated forms of the parent drug. The products of metabolism, and some unchanged drug, are excreted in the urine.
Excretion: The principal route of elimination of ketorolac and its metabolites is renal. About 92% of a given dose is found in the urine, approximately 40% as metabolites and 60% as unchanged ketorolac. Approximately 6% of a dose is excreted in the feces. A single-dose study with 10 mg ketorolac tromethamine (n=9) demonstrated that the S-enantiomer is cleared approximately two times faster than the R-enantiomer and that the clearance was independent of the route of administration. This means that the ratio of S/R plasma concentrations decreases with time after each dose. There is little or no inversion of the R- to S- form in humans. The clearance of the racemate in normal subjects, elderly individuals and in hepatically and renally impaired patients is outlined in Table 2
 
Ketorolac tromethamine injection may be used as a single or multiple dose on a regular or “prn” schedule for the management of moderately severe, acute pain that requires analgesia at the opioid level, usually in a postoperative setting. Hypovolemia should be corrected prior to the administration of ketorolac tromethamine (see WARNINGS - Renal Effects). Patients should be switched to alternative analgesics as soon as possible, but ketorolac tromethamine therapy is not to exceed 5 days.
When administering ketorolac tromethamine injection, the IV bolus must be given over no less than 15 seconds. The IM administration should be given slowly and deeply into the muscle. The analgesic effect begins in ~30 minutes with maximum effect in 1 to 2 hours after dosing IV or IM. Duration of analgesic effect is usually 4 to 6 hours.
Single-Dose Treatment: The Following Regimen Should Be Limited To Single Administration Use OnlyIM Dosing:
• Patients < 65 years of age: One dose of 60 mg.
• Patients &#8805; 65 years of age, renally impaired and/or less than 50 kg (110 lbs) of body weight: One dose of 30 mg.
IV Dosing:
• Patients < 65 years of age: One dose of 30 mg.
• Patients &#8805; 65 years of age, renally impaired and/or less than 50 kg (110 lbs) of body weight: One dose of 15 mg.
Multiple-Dose Treatment (IV or IM)
• Patients < 65 years of age: The recommended dose is 30 mg ketorolac tromethamine injection every 6 hours. The maximum daily dose for these populations should not exceed 120 mg.
• For patients &#8805; 65 years of age, renally impaired patients (see WARNINGS), and patients less than 50 kg (110 lbs):
The recommended dose is 15 mg ketorolac tromethamine injection every 6 hours. The maximum daily dose for these populations should not exceed 60 mg.
For breakthrough pain, do not increase the dose or the frequency of ketorolac tromethamine. Consideration should be given to supplementing these regimens with low doses of opioids “prn” unless otherwise contraindicated
 
A. I like the Scopolamine patch idea. SRNA asks how much more effective the patch is vs.
EMEND ® (aprepitant) and routine anti-emetic meds.


B. SRNA asks how much decadron will you give this fat diabetic patient. Will it elevate her blood glucose and if so, for how long? Will Decadron elevate the blood glucose of non-diabetics?

C. SRNA asks if Reglan is an effective ant-emetic. If so, at what dose?

D. SRNA asks if intraop Droperidol is a safe and effective anti-emetic compared to Odansetron. Would you give both? If so, when would you give them?

E. SRNA asks how much Ketorolac you will give this patient with normal renal function. Does the dosage change for I.M. vs I.V.? Does the dosage change if the Ketorolac will be continued postoperatively by the surgeon for the next 24 hours?


Anyone want to take a stab at A-D? Anyone?
 
Anyone want to take a stab at A-D? Anyone?

I'd like to a stab at the case....

Pre-op - How much insulin does she normally take and how much did she take today? Regardless, I'm checking the BG intraop and treating as needed. Did she take her Protonix and Zantac today? When was the last time she ate or drank anything whatsoever? Did she take her lisinopril today?

Given the history of vomiting for days I'd explore this further to determine if it was truly from the anesthetic. If so, I'd discuss the merits of a TIVA with my attending. Personally, I'd lean towards a TIVA. I've never used scopolamine pre-op but I'd like to try. I've yet to give decadron to a known diabetic, but I'd discuss it with my attending.

I'd discuss with my attending the merits of giving reglan and bicitra before rolling back to the OR.

Airway - No chance this lady gets an LMA. Obese, GERD, laparoscopic procedure. Glidescope for backup. I'm taking a look with DL with bougie on backup if needed/possible. Intubating LMA ready to go also if none of the above works.

Intraop - I'm putting the OG in before we get going...right after intubation. Check BG and treat PRN. Hopefully I'm running the TIVA. If she took her lisinopril recently there's a chance she's pretty volume deplete. I'm making sure I cover her deficit and then some believing it could possibly help with PONV as well. She'll get droperidol and zofran definitely, and possibly decadron depending on the feelings of the attending.

Postop - Promethazine PRN for PONV. If it gets severe she'll get small boluses (~10mg) of propofol to help as well.


I'll take a look at your A-D, but the SRNA would be told to do her own research.
 
1. airway: this is an awake fiberoptic/glidescope intubation. i like topicalizing just upper airway and taking a quick look with glidescope. if good view - patient goes to sleep. no reason to believe she would be difficult to ventilate.
no LMA. although one can ventilate with relatively high peaks via a supreme, it's just not worth it - her obesity and laparoscopy may necessitate higher pressures at times.

2. glucose - check preop and q2 hours intraop.

3. PONV - dexameth 4mg, reglan 10mg up front. zofran towards the end. leave drop for rescue in pacu. do NOT use nitrous or VA. just run her on propofol. consider avoiding narcotic. consider not reversing (just use sux) or using a lower dose of neo.

4. toradol. the dose is 30mg. one time dose of 60mg may be given IM. however, due to this patient's HTN and IDDM and GERD i would be concerned about end organ vulnerability and would like to use the lowest effective dose.
 
Anyone want to take a stab at A-D? Anyone?

A. interesting question. I believe aprepitant has better antiemetic activity over a 48 hour period compared to other antiemetics, but not sure about the patch.

B. gotta look this one up too. on call now, so maybe later.

C. I have to look up the effective concentration. Studies have shown that 10mg is inneffective as an antiemetic.

D. Droperidol has a long standing history of safe antiemetic use with no reported significant arrythmias at doses used for emesis despite the black box warning. It can be used safely with ondansetron, but since both cause QT prolongation I wouldnt give both at once. I believe the maximum prolongation is shown to be around 5-6 minutes after administration with droperidol. Im not sure at what time the max is for ondansetron, but I tend to wait at least a half hour between the two while watching the EKG for any obvious prolongation.
 
Great posts Blade!

A. I would NOT give ondansetron and droperidol ROUTINELY together. Although I am an avid defender of droperidol, it is a more "dangerous" drug to be given in terms of the medicolegal arena.

In the USA, for routine cases, I would give ondansetron. For rescue, I would weigh the risk benefit of an additive effect of prolonging QT in each individual pt of whether preventing or stopping nausea is better than the dose-effect, additive effect of giving two QT prolongers for possible arrhythmogenicity.

Although decadron can raise the CBG of non-diabetics, a dose of 4 mg in adults is equally efficacious as higher doses with much fewer SE (like CBG inc). Raising the CBG acutely in many pts is less important than having an admission for PONV. HOWEVER, if the pt is having major surgery that stimulates the stress response and may lead to all kinds of neurohumoral badness, I would think twice about giving decadron. BUT, since I would likely be treating their sugars in this situation, no harm in giving it...?
 
You guys know I have all the data/studies for my questions. I appreciate the responses. If I was your attending or Oral Board examiner how would you answer A-D? Jeff took a good stab at it but how about some data?

There are studies for EVERY question posed by me (A-D) and I believe they are clinically relevant to everyday cases.

Southpaw you have responded in an excellent approach to the case. How about digging a little deeper?
 
A. interesting question. I believe aprepitant has better antiemetic activity over a 48 hour period compared to other antiemetics, but not sure about the patch.

B. gotta look this one up too. on call now, so maybe later.

C. I have to look up the effective concentration. Studies have shown that 10mg is inneffective as an antiemetic.

D. Droperidol has a long standing history of safe antiemetic use with no reported significant arrythmias at doses used for emesis despite the black box warning. It can be used safely with ondansetron, but since both cause QT prolongation I wouldnt give both at once. I believe the maximum prolongation is shown to be around 5-6 minutes after administration with droperidol. Im not sure at what time the max is for ondansetron, but I tend to wait at least a half hour between the two while watching the EKG for any obvious prolongation.


Good answers. You are correct A-D but can you be more specific?


Does Emend have a role as an anti-emetic in this patient? Would you use it if available instead of the patch in any situations? Would you use Emend with the scop patch?


Should we be concerned about blood glucose levels in this patient after a single dose of decadron? If so, for how long will the decadron elevate her blood sugar? What dose of decadron will you choose? What is the minimum effective doae of decadron as proven by clinical data and what is the maximum rec. dose for anti-nausea? How much will you give?

In some European countries Reglan is used at a higher dosage routinely.
Is that doage more effective? Would you consider giving the higher dosage at induction? What about divided doses of Reglan? Some upfront and the rest at induction?

You nailed the droperidol question. So when would you give the drop?
How much? Any data showing the risk of Q-T prolongation vs. Odansetron? THis case should take about an hour from induction to wake-up.
 
1. airway: this is an awake fiberoptic/glidescope intubation. i like topicalizing just upper airway and taking a quick look with glidescope. if good view - patient goes to sleep. no reason to believe she would be difficult to ventilate.
no LMA. although one can ventilate with relatively high peaks via a supreme, it's just not worth it - her obesity and laparoscopy may necessitate higher pressures at times.

2. glucose - check preop and q2 hours intraop.

3. PONV - dexameth 4mg, reglan 10mg up front. zofran towards the end. leave drop for rescue in pacu. do NOT use nitrous or VA. just run her on propofol. consider avoiding narcotic. consider not reversing (just use sux) or using a lower dose of neo.

4. toradol. the dose is 30mg. one time dose of 60mg may be given IM. however, due to this patient's HTN and IDDM and GERD i would be concerned about end organ vulnerability and would like to use the lowest effective dose.


Good responses and correct. Still, dig deeper and look for data supporting your answers and hypothetically, answer the SRNA's questions.
 
4. toradol. the dose is 30mg. one time dose of 60mg may be given IM. however said:
Jeff,

The Big Dog General Surgeon asks you to give this patient Toradol 30 mg I.V. and then 30 mg I.V. He says that will be the only dose of toradol she receives post op.

How do you respond? Will you give that dose?
 
A. interesting question. I believe aprepitant has better antiemetic activity over a 48 hour period compared to other antiemetics, but not sure about the patch.

B. gotta look this one up too. on call now, so maybe later.

C. I have to look up the effective concentration. Studies have shown that 10mg is inneffective as an antiemetic.

D. Droperidol has a long standing history of safe antiemetic use with no reported significant arrythmias at doses used for emesis despite the black box warning. It can be used safely with ondansetron, but since both cause QT prolongation I wouldnt give both at once. I believe the maximum prolongation is shown to be around 5-6 minutes after administration with droperidol. Im not sure at what time the max is for ondansetron, but I tend to wait at least a half hour between the two while watching the EKG for any obvious prolongation.


A great study from ANESTHESIOLOGY showing low dose droperidol (0.625-1.25mg I.V.) is both safe and effective.

I would separate the administration of droperidol and Odansetron. I would give the droperidol after the start of the case (at some point where things settle down) and the Odansetron near the end of the case (last 30 minutes).

http://www.fma.org.mx/LinkClick.aspx?fileticket=w0yRwKDL6eI=&tabid=87&mid=396
 
Jeff,

The Big Dog General Surgeon asks you to give this patient Toradol 30 mg I.V. and then 30 mg I.V. He says that will be the only dose of toradol she receives post op.

How do you respond? Will you give that dose?

I would hold off on redosing ketorolac or any other NSAID for at least 6 hours following the initial ketorolac dose. Also, although the patient's labs were "normal", her long standing diabetes puts her at increased risk of nephropathy. I would call it a day after the first 30, and might consider cutting that first dose to 15 mg.
 
D. Droperidol has a long standing history of safe antiemetic use with no reported significant arrythmias at doses used for emesis despite the black box warning. It can be used safely with ondansetron, but since both cause QT prolongation I wouldnt give both at once. I believe the maximum prolongation is shown to be around 5-6 minutes after administration with droperidol. Im not sure at what time the max is for ondansetron, but I tend to wait at least a half hour between the two while watching the EKG for any obvious prolongation.

I can tell you that in continental Europe nobody cares about monitoring the ECG after drop. The whole black box warning is complete bogus and certainly commercially motivated.
 
I would hold off on redosing ketorolac or any other NSAID for at least 6 hours following the initial ketorolac dose. Also, although the patient's labs were "normal", her long standing diabetes puts her at increased risk of nephropathy. I would call it a day after the first 30, and might consider cutting that first dose to 15 mg.

If only your bite is as good as your bark.:thumbup:
 
Since this is a certainly, could you provide the evidence to corroborate the above?

I don't have any evidence to support his statement (mostly because I don't want to look it up-there are numerous editorials on the topic), but you can bet that he is 100% correct in his statement that droperidol was "blackballed" for financial incentive to the makers of the tron drugs. Everyone knew that few would be eager to put money into studying an old drug that was long ago off patent to make sure it was safe. Studies have since occurred, but it took years and the damage was already done. At my hospital, it is so hard to get droperidol that it is not worth the trouble, especially now that ondansetron is off patent. As with everything else, follow the money trail.
 
I don't have any evidence to support his statement (mostly because I don't want to look it up-there are numerous editorials on the topic), but you can bet that he is 100% correct in his statement that droperidol was "blackballed" for financial incentive to the makers of the tron drugs. Everyone knew that few would be eager to put money into studying an old drug that was long ago off patent to make sure it was safe. Studies have since occurred, but it took years and the damage was already done. At my hospital, it is so hard to get droperidol that it is not worth the trouble, especially now that ondansetron is off patent. As with everything else, follow the money trail.

I still would be interested in seeing a reference./

We use drop all the time but always at low doses, .625 mg.
 
Hey guys/gals we still have some unaswered questions here. A thru C could use some thorough responses with peer reviewed references.

I will post the answers to my questions late Sunday or Monday. I hope someone takes 5 minutes out of his/her schedule to look up just one question.

Every Resident should know the peer reviewed literature on Decadron and effective dose range to prevent Nausea/Vomiting.(there really is a range in the literature). In addition, new evidence suggests how a single dose of decadron affects blood sugar in diabetics and non-diabetics.

I am hoping Proreal, POD, Jeff, etc. can come up with something before Monday.

Blade
 
Does Emend have a role as an anti-emetic in this patient? Would you use it if available instead of the patch in any situations? Would you use Emend with the scop patch?


Should we be concerned about blood glucose levels in this patient after a single dose of decadron? If so, for how long will the decadron elevate her blood sugar? What dose of decadron will you choose? What is the minimum effective doae of decadron as proven by clinical data and what is the maximum rec. dose for anti-nausea? How much will you give?

In some European countries Reglan is used at a higher dosage routinely.
Is that doage more effective? Would you consider giving the higher dosage at induction? What about divided doses of Reglan? Some upfront and the rest at induction?
Quote:
Originally Posted by BLADEMDA
A. I like the Scopolamine patch idea. SRNA asks how much more effective the patch is vs.
EMEND ® (aprepitant) and routine anti-emetic meds.


B. SRNA asks how much decadron will you give this fat diabetic patient. Will it elevate her blood glucose and if so, for how long? Will Decadron elevate the blood glucose of non-diabetics?

C. SRNA asks if Reglan is an effective ant-emetic. If so, at what dose?

 
I still would be interested in seeing a reference./

We use drop all the time but always at low doses, .625 mg.


Anesthesiology:
October 2007 - Volume 107 - Issue 4 - pp 524-526
doi: 10.1097/01.anes.0000282093.29212.b6
Editorial Views

Droperidol-induced Proarrhythmia: The Beginning of an Answer?

Charbit, Beny M.D.; Funck-Brentano, Christian M.D., Ph.D.

Free Access





Droperidol has several electrophysiologic characteristics that the guidelines view as potentially harmful. Droperidol blocks HERG, one of the main ionic currents that underlies QT interval duration.4,5 Results of clinical evaluations are not consistent. White et al.6 failed to demonstrate statistically significant QT interval prolongation with 1.25 mg droperidol. However, they found a 22-ms QT prolongation with droperidol compared with 12 ms with placebo, and their study was only powered to detect QTc change of 15% (i.e., approximately 60 ms). In a study that was not placebo controlled, we found a 17-ms QT interval prolongation with 0.75 mg droperidol. Therefore, although not definitively proven or studied according to the guidelines, droperidol can prolong the QT interval even at a low dose and belongs to the increasing list of noncardiac drugs for which some form of warning is justified.
Finally, if one considers the estimated maximal risk of droperidol-induced proarrhythmia (3.6 per 10,000), this would still represent a risk 60 times greater than that of epidural hematoma after epidural anesthesia, whose risk is approximately 1 in 168,000 in the United States.12 Even if it is not fatal, no anesthesiologist worldwide would consider the risk of epidural hematoma negligible and accept to perform everyday epidural anesthesia without any caution. Therefore, although the precise format of the warning certainly remains a matter for debate, the warning itself is still justified because one has to be more stringent on safety issues than on efficacy issues.
Beny Charbit, M.D.,
Christian Funck-Brentano, M.D., Ph.D.,
Université Pierre et Marie Curie-Paris 6, Department of Pharmacology; Assistance Publique-Hôpitaux de Paris, Saint-Antoine Hospital, Division of Clinical Pharmacology; Institut National de la Santé et de la Recherche Médicale (INSERM) CIC9304, Paris, France. [email protected]

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References

1. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, Kovac A, Philip BK, Sessler DI, Temo J, Tramer MR, Watcha M: Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003; 97:62-71
Cited Here... | View Full Text | PubMed | CrossRef

2. Nuttall GA, Eckerman KM, Jacob KA, Pawlaski EM, Wigersma SK, Shirk Marienau ME, Olivier WC, Narr BJ, Ackerman MJ: Does low-dose droperidol administration increase the risk of drug-induced QT prolongation and torsade de pointes in the general surgical population? Anesthesiology 2007; 107:531-6
Cited Here... | View Full Text | PubMed | CrossRef

3. Roden DM: Drug-induced prolongation of the QT interval. N Engl J Med 2004; 350:1013-22
Cited Here... | PubMed | CrossRef

4. Drolet B, Zhang S, Deschenes D, Rail J, Nadeau S, Zhou Z, January CT, Turgeon J: Droperidol lengthens cardiac repolarization due to block of the rapid component of the delayed rectifier potassium current. J Cardiovasc Electrophysiol 1999; 10:1597-604
Cited Here... | PubMed | CrossRef

5. Schwoerer AP, Blutner C, Brandt S, Binder S, Siebrands CC, Ehmke H, Friederich P: Molecular interaction of droperidol with human ether-a-go-go-related gene channels: Prolongation of action potential duration without inducing early afterdepolarization. Anesthesiology 2007; 106:967-76
Cited Here... | View Full Text | PubMed | CrossRef

6. White PF, Song D, Abrao J, Klein KW, Navarette B: Effect of low-dose droperidol on the QT interval during and after general anesthesia: A placebo-controlled study. Anesthesiology 2005; 102:1101-5
Cited Here... | View Full Text | PubMed | CrossRef

7. Charbit B, Albaladejo P, Funck-Brentano C, Legrand M, Samain E, Marty J: Prolongation of QTc interval after postoperative nausea and vomiting treatment by droperidol or ondansetron. Anesthesiology 2005; 102:1094-100
Cited Here... | View Full Text | PubMed | CrossRef

8. Pratt CM, Ruberg S, Morganroth J, McNutt B, Woodward J, Harris S, Ruskin J, Moye L: Dose-response relation between terfenadine (Seldane) and the QTc interval on the scalar electrocardiogram: Distinguishing a drug effect from spontaneous variability. Am Heart J 1996; 131:472-80
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9. Woosley RL, Chen Y, Freiman JP, Gillis RA: Mechanism of the cardiotoxic actions of terfenadine. JAMA 1993; 269:1532-6
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10. Hanrahan JP, Choo PW, Carlson W, Greineder D, Faich GA, Platt R: Terfenadine-associated ventricular arrhythmias and QTc interval prolongation: A retrospective cohort comparison with other antihistamines among members of a health maintenance organization. Ann Epidemiol 1995; 5:201-9
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11. Kuryshev YA, Brown AM, Wang L, Benedict CR, Rampe D: Interactions of the 5-hydroxytryptamine 3 antagonist class of antiemetic drugs with human cardiac ion channels. J Pharmacol Exp Ther 2000; 295:614-20
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12. Ruppen W, Derry S, McQuay H, Moore RA: Incidence of epidural hematoma, infection, and neurologic injury in obstetric patients with epidural analgesia/anesthesia. Anesthesiology 2006; 105:394-9
 
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Anesthesiology:
October 2007 - Volume 107 - Issue 4 - pp 531-536
doi: 10.1097/01.anes.0000281893.39781.64
Clinical Investigations

Does Low-dose Droperidol Administration Increase the Risk of Drug-induced QT Prolongation and Torsade de Pointes in the General Surgical Population?

Nuttall, Gregory A. M.D.; Eckerman, Karen M. C.R.N.A. M.N.A.; Jacob, Kelly A. C.R.N.A. M.N.A.; Pawlaski, Erin M. C.R.N.A. M.N.A.; Wigersma, Susan K. C.R.N.A. M.N.A.; Marienau, Mary E. Shirk C.R.N.A., M.S.; Oliver, William C. M.D.; Narr, Bradly J. M.D.; Ackerman, Michael J. M.D., Ph.D.

Free Access











Discussion

We found no evidence supporting the black box warning placed on droperidol by the FDA when used to treat PONV in the surgical population. Droperidol use as an antiemetic in the perioperative period decreased from 12% to 0% after the December 2001 FDA black box warning for droperidol because of concerns regarding drug-induced LQTS. There was no change in the incidence of TdP with the commonly used low-dose droperidol versus no droperidol use in a large number of surgical patients. This indicates that the incidence of TdP is at most 1 in 16,791 (95% CI, 10,173-25,607) droperidol exposures, with that 1 patient also having received 1.25 mg droperidol 10 h before the event and having received ondansetron, another implicated drug for possible drug-induced TdP 5 h before the event. Given the short half-life of droperidol, it is unlikely that droperidol contributed to this patient's dysrhythmia. This indicates that the FDA black box warning is excessive and unnecessary for low-dose droperidol therapy. The data suggest that the guidelines initiated by the FDA for mandatory electrocardiographic screening before administration of droperidol are also unnecessary for patient safety.
 
But is droperidol given at the usual antiemetic doses QT safe? Our data would certainly suggest that it is. White et al.18 performed a randomized, double-blind, placebo-controlled trial to evaluate the intraoperative and postoperative effects of low-dose droperidol (0.625 and 1.25 mg intravenous) on the QT interval when used for antiemetic prophylaxis during a standardized general anesthetic. They found that the use of a small dose of droperidol (0.625-1.25 mg intravenous) for antiemetic prophylaxis during general anesthesia was not associated with a statistically significant increase in the QT interval compared with saline. Further, there was no evidence of any droperidol-induced QT prolongation immediately after surgery.
 
OK I buy the above and agree with it. It's pretty consistent with the way I was trained (although old habits die hard with some folks). I am not a conspiracy theorist though and have a hard time buying that the warning is "certainly commercially motivated". I know big pharm has their tentacles everywhere and are driven by the almighty dollar but I would be interested to see a little more proof before I buy this assertion.
 
OK I buy the above and agree with it. It's pretty consistent with the way I was trained (although old habits die hard with some folks). I am not a conspiracy theorist though and have a hard time buying that the warning is "certainly commercially motivated". I know big pharm has their tentacles everywhere and are driven by the almighty dollar but I would be interested to see a little more proof before I buy this assertion.

I am not sure that there is anything that would prove it beyond a shadow of a doubt. However, a lot of people feel this way about how this situation occurred. I did a simple Google search of "conspiracy, droperidol, black box" and there are quite a few pertinent hits. None with much proof as you request, but quite a few coincidences. Probably a bit more to it than the "we never went to the moon" conspiracy theorists.:)
If I had the energy, I might be able to find more. Paul White out of UTSW has written a lot on this topic. I believe he is a big proponent of droperidol as a safe, inexpensive, and effective antiemetic.
 
A 55 year mildly obese female presents for a Lap. Cholecystectomy.
Her PMH is significant for DM (IDDM), HTN, GERD (controlled on meds) and possible difficult intubation previously for appy. Also, she states anesthesia makes her "throw up for days".

PSH:

Open Appendectomy at age 20 under GA

Meds:

Insulin
Lisinopril
Protonix
Zantac

Labs:

Glucose (fingerstick) 180. other labs WNL EKG;WNL


Wt= 100Kg Ht: 5'7"

What is your plan here?

The SRNA wants to use an LMA. Opinions? Pre-op meds? Any further studies?

assess airway, get history of diff. intubation, refine airway plan depending on details/airway exam.

assess ponv history/risk. if legit, tiva (remi/propofol) with ETT ("mildly obese" 100kg diabetics don't get lma's when their abdomen's are insuflated). good preox, twenty seconds to fiddle with one hand/oral airway or two hand w/ pressure control ventilation. if difficulty, LMA. if LMA doesn't seat, quick look with best blade--LTA for airway anesthesia--if i can see arytenoids but can't pass tube, i'd probably give a small dose of sux to loosen her up versus stop the remi/propofol and let her wake up.

i'm still relatively new at this, but i've developed the strong suspicion that almost any patient with normal airway anatomy (i.e. no tumors/goiters) can be mask ventilated with a pressure control/pressure limiting on the vent. i'm not a cowboy, but we'll see if my opinion on this ever chagnes.

don't really care all that much about the glucose--we can give some insulin, i guess, and check once during the case.
 
Robert,
I believe that any benefit of propofol TIVA for PONV prophylaxis would be lost by adding remi. I don't use remi that often, but I believe it is notorious or PONV. Let's see if anyone agrees or disagrees on that one.
 
Robert,
I believe that any benefit of propofol TIVA for PONV prophylaxis would be lost by adding remi. I don't use remi that often, but I believe it is notorious or PONV. Let's see if anyone agrees or disagrees on that one.

Don't have thecitation in front of me but a 2007 study on 40000 patients in the uk showed 25% decrease in anesthesia related admissions, including ponv. We use it remi routinely, save for lack of post-op pain control. Avoidance of potent agent and nitrous is more important for avoidance of ponv, unless tts patient doesn't have ponv but po(piod)nv.
 
1: Br J Anaesth. 2006 Aug;97(2):164-70. Epub 2006 May 12. Links

Comment in: Br J Anaesth. 2006 Dec;97(6):896-7. Br J Anaesth. 2006 Nov;97(5):751; author reply 751-2. Blood glucose concentration profile after 10 mg dexamethasone in non-diabetic and type 2 diabetic patients undergoing abdominal surgery.

Hans P, Vanthuyne A, Dewandre PY, Brichant JF, Bonhomme V.
University Department of Anaesthesia and Intensive Care Medicine, CHR de la Citadelle, Liege University Hospital , Belgium. [email protected]
BACKGROUND: Dexamethasone prevents postoperative nausea and vomiting but may increase blood glucose. We compared blood glucose concentrations after dexamethasone in non-diabetic and type 2 diabetic patients undergoing surgery and looked for any association with preoperative glycosylated haemoglobin [HbA (1c)] and BMI. METHODS: Sixty three patients were enrolled: 32 were non-diabetic (Group ND) and 31 type 2 diabetic (Group D) without insulin treatment. Anaesthesia was induced using i.v. anaesthetic agents and maintained with sevoflurane. All patients received 10 mg dexamethasone at induction. Blood glucose concentrations were measured at induction and then every 60 min for 240 min. Data were analysed using anova. Effects of HbA (1c) and BMI were investigated using linear correlation and logistic regression. RESULTS: Blood glucose concentrations increased significantly over time and peaked at 120 min after 10 mg dexamethasone in both groups. The magnitude of increase was comparable between the groups [mean (SD) 29 (19) and 35 (19)% of baseline in Group D and Group ND, respectively]. Maximum concentrations were higher in Group D [8.97 (1.51) mmol litre(-1), range 6.67-12.94 mmol litre(-1)] than in Group ND [7.86 (1.00) mmol litre(-1), range 5.78-10.00 mmol litre(-1)]. There was a significant correlation between the maximum concentrations and BMI (R(2)=0.21) or HbA (1c) (R(2)=0.26). Logistic regression analysis revealed that the higher the BMI, the lower the HbA (1c) threshold associated with an increased probability (>0.5) of observing blood glucose levels higher than 8.33 mmol litre(-1) during 240 min after dexamethasone administration. Similarly, the higher the HbA (1c), the lower the BMI threshold associated with the same probability. CONCLUSIONS: After 10 mg dexamethasone, blood glucose levels increase in non-diabetic and type 2 diabetic patients undergoing abdominal surgery. Poorly controlled diabetes and severe obesity can influence the development of hyperglycaemia
 
Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting

[SIZE=+1]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 [/SIZE]
spacer.gif
[FONT=arial, helvetica][SIZE=+1]ABSTRACT[/SIZE].
[FONT=arial, helvetica]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. .
[FONT=arial, helvetica]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. .
[FONT=arial, helvetica]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. .
[FONT=arial, helvetica]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. .
 
So, in order to get this case finished I though an answer to the "effective" dose of Decadron to prevent post operative Nausea and Vomiting would be a good place to start.

The effective dose range of a single I.V. administration of Decadron is 2-12 mg. The 2 mg dosage has a higher incidence of Nausea than the 4-8 mg dosage. Many studies advocate the 8 mg dosage in the U.S. and the 10 mg dosage in Europe. I prefer the studies which show the 4 mg dosage to be as effective as the higher dosage.

Anesth Analg. 2007 Apr;104(4):808-14.
Related Articles, Links

[SIZE=+1]Ondansetron and dexamethasone dose combinations for prophylaxis against postoperative nausea and vomiting.[/SIZE]

Paech MJ, Rucklidge MW, Lain J, Dodd PH, Bennett EJ, Doherty DA.

Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth, Western Australia. [email protected]

BACKGROUND: Patients at high risk of postoperative nausea and vomiting often receive more than one prophylactic antiemetic drug. In this study we sought to determine whether one or more of four dose combinations of dexamethasone and ondansetron was superior in efficacy. METHODS: In a randomized, double-blind trial of four dose combinations, women having day-surgical gynecologic laparoscopy received IV dexamethasone and ondansetron 4 + 4 mg (Group D4/O4, n = 154), 4 + 2 mg (Group D4/O2, n = 151), 2 + 4 mg (Group D2/O4, n = 154), or 2 + 2 mg (Group D2/O2, n = 155). RESULTS: The groups were not significantly different for predicted risk or characteristics. The incidence of vomiting until discharge did not differ significantly (5%, 4%, 9% and 8% for Groups D4/O4, D4/O2, D2/O4 and D2/O2 respectively, P = 0.17), nor were there significant differences among groups in the incidence of vomiting until 24 h postoperatively, no nausea and no vomiting, antiemetic treatment, neither vomiting nor antiemetic treatment (80%-83% across groups), or inpatient satisfaction and recovery scores, or time to discharge. Average nausea scores were low in all groups, but the incidence of nausea until 24 h postoperatively was significantly higher among groups receiving only 2 mg of dexamethasone (P < 0.03). CONCLUSIONS: All combinations were associated with a low incidence of vomiting and rescue treatment, with dexamethasone 2 mg plus ondansetron 2 mg not significantly different to other dose combinations except that groups receiving 2 mg dexamethasone had a more frequent incidence of nausea.
 
Last edited:
Anasthesiol Intensivmed Notfallmed Schmerzther. 2009 Apr;44(4):286-94; quiz 295. Epub 2009 Apr 14. Links

[Postoperative nausea and vomiting: rational algorithms for prevention and treatment based on current evidence]

[Article in German]


Kranke P, Eberhart LH.
Klinik und Poliklinik für Anästhesiologie des Universitätsklinikums Würzburg. [email protected]
Postoperative nausea and vomiting (PONV) constitutes a major unpleasant symptom in the postoperative period. The prevention of PONV is judged equally important as the prevention of postoperative pain. Therefore, a working PONV-algorithm should be as self-evident as the approach to prevent and treat postoperative pain. None of the currently available pharmacological interventions is able to totally abolish PONV. However, using a multimodal approach with the combination of various antiemetic interventions, a substantial reduction or even elimination of PONV is already feasible. As a rule of thumb, each effective antiemetic intervention will lead to a relative risk reduction of approximately 30 %. Well documented interventions in terms of the aforementioned efficacy are the administration of ondansetron 4 mg, dexamethasone 4 mg, droperidol 1,25mg and dimenhydrinate 62 mg, as well oral Aprepitant. Metoclopramide may play a role for instance in a multimodal approach. Apart from the administration of antiemetics, the avoidance of inhalational anaesthetics by using propofol is associated with a comparable risk reduction. In general, using a risk-dependent approach, e.g. based on a simplified risk score, allows to avoid administering antiemetics to patients at low risk. However, due to the difficulties associated with the implementation of risk-score based algorithms and the inherent weaknesses of clinical risk scores to predict PONV in an individual patient, a general (multimodal) approach seem to be justified as well. Considering the fact that the currently available antiemetics are associated with few side effects, the administration of prophylactic antiemetics should not be associated with a high hurdle in the clinical setting. In case of any doubts regarding the individual risk, it seems justified to expand the (multimodal) prophylaxis rather than to wait until PONV occurs and impairs patient comfort.
 
Br J Anaesth. 2007 Aug;99(2):202-11. Epub 2007 May 30. Links

Single-dose aprepitant vs ondansetron for the prevention of postoperative nausea and vomiting: a randomized, double-blind phase III trial in patients undergoing open abdominal surgery.

Diemunsch P, Gan TJ, Philip BK, Girao MJ, Eberhart L, Irwin MG, Pueyo J, Chelly JE, Carides AD, Reiss T, Evans JK, Lawson FC; Aprepitant-PONV Protocol 091 International Study Group.
Services d'Anesthesiologie-Reanimation Chirurgicale, CHU, Hôpital de Hautepierre, 1 Avenue de Moliere, Strasbourg 67000, France. [email protected]
BACKGROUND: The neurokinin(1) antagonist aprepitant is effective for prevention of chemotherapy-induced nausea and vomiting. We compared aprepitant with ondansetron for prevention of postoperative nausea and vomiting. METHODS: Nine hundred and twenty-two patients receiving general anaesthesia for major abdominal surgery were assigned to receive a single preoperative dose of oral aprepitant 40 mg, oral aprepitant 125 mg, or i.v. ondansetron 4 mg in a randomized, double-blind trial. Vomiting episodes, use of rescue therapy, and nausea severity (verbal rating scale) were documented for 48 h after surgery. Primary efficacy endpoints were complete response (no vomiting and no use of rescue therapy) 0-24 h after surgery and no vomiting 0-24 h after surgery. The secondary endpoint was no vomiting 0-48 h after surgery. RESULTS: Aprepitant at both doses was non-inferior to ondansetron for complete response 0-24 h after surgery (64% for aprepitant 40 mg, 63% for aprepitant 125 mg, and 55% for ondansetron, lower bound of 1-sided 95% CI > 0.65), superior to ondansetron for no vomiting 0-24 h after surgery (84% for aprepitant 40 mg, 86% for aprepitant 125 mg, and 71% for ondansetron; P < 0.001), and superior for no vomiting 0-48 h after surgery (82% for aprepitant, 40 mg, 85% for aprepitant, 125 mg, and 66% for ondansetron; P < 0.001). The distribution of peak nausea scores was lower in both aprepitant groups vs ondansetron (P < 0.05). CONCLUSIONS: Aprepitant was non-inferior to ondansetron in achieving complete response for 24 h after surgery. Aprepitant was significantly more effective than ondansetron for preventing vomiting at 24 and 48 h after surgery, and in reducing nausea severity in the first 48 h after surgery. Aprepitant was generally well tolerated.
 
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